New Client Referrals – Essentia Health

Name *

First

Last

Email *

Phone Number *

Your Address *

We have programs in the Bayside region of Melbourne, Mona Vale NSW and the Gold Coast in Queensland.

GPs Details &/or Psychiatrist Information

Your Current Therapist's Details *

If you currently have a Psychologist, Social Worker or Counsellor please provide their details. If you do not have a therapist please type “No current therapist”

Which one of our services are you seeking?

Select all the services above that are applicable to you.

If you chose "DBT on the previous question, please indicate which DBT treatment approach you are seeking *

Please tick all services which you are seeking. If you have no preference with skills group format please tick all groups

Please indicate your preferred day of the week to receive our clinical services? *

If you have no preference please tick all days!

Upload any Referral Information

Click or drag a file to this area to upload.

Upload your mental health plan or referral from your GP or Psychiatrist if you have referral documents.

Comment or Message *

New Client Referral Form