Online Referral Form

Living Without Worry Counselling
and Allied Health

Together, we can do more than we can do alone. Let’s bring our abilities and passions together to affect real change.

There are many ways to join us and support our mission. Contact us to find out more about counselling and NDIS support coordination, fundraising events, and ways that you can get our message to your friends and family.

If you need assistance completing the form phone us on 1300 889 609

LWWHC Referral and Intake Form

This referral and intake form is to provide LWWHC with the necessary details to provide the best matching service and clinician.

LWWHC Region(Required)

Telehealth is available Nationwide outside of the Southeast Queensland area.

Priority(Required)

If you require urgent assistance (within 48 hours) please contact us on 1300 889 609.

Client's First Name(Required)

Client's Middle Name

Client's Surname(Required)

Client's Age (bracket)(Required)

Client's Date of Birth (Date/Month/Year)

Phone(Required)

Email(Required)

Address(Required)

Street Address Suburb State / Province / Region ZIP / Postal Code Country

Funding Source(Required)

Email address for invoicing(Required)

Service(s) Type(Required)

If you need more than one service enter them into the information section at of this enquiry form.

Client's current health/disability issue(s) related to this referral

Reason for Referral(Required)

Referrer's Name

Please enter First Name and Surname.

Referrer's Email

Referrer's Phone Number

Preferred Language(Required)

A language translater can be arranged.

General Practitioner's Name (GP)

Practice Name

Practice Phone Number

Practice Email

Select any medical conditions the client has currently or has had in the past:

Asthma

Diabetes

High Blood Pressure

Cancer

Arthritis

Cardiac problems

Anxiety

Depression

PTSD

Mental Health (Other)

Other health condition/s (briefly describe)

Allergies (detail any known allergies)

Client's Representative (Optional)

Client's Preferred Contact Method(Required)

Client's Preferred Appointment Type(Required)

NDIS Reference Number (if relevant)

NDIS Plan Management (if relevant)

Plan Manager's Name (if relevant)

Plan Manager's Phone number (if relevant)

Plan Manager's Email (if relevant)

NDIS Plan Start Date (if relevant)

NDIS Plan End Date (if relevant)

Initial Risk Assessment

Is a home visit expected to be conducted by LWWHC clinician?(Required)

Yes

Unknown

Is a community visit expected to be conducted with the client by LWWHC clinician?

Yes

Unknown

If a community visit is expected with the client by LWWHC clinician, which type?

LWWHC Appointment

GP Appointment

Shopping

Cafe

Park

Family/Friend Visit

Event

Location of door to enter

Is the client or other occupants of the property known to be potentially aggressive, violent or disturbed?

Is there evidence that the client or other occupants at the premises may be under the influence of alcohol or drugs?

Will the client require a home visit at night or outside of normal working hours (Mon-Fri 8am-4pm)?

Mon-Fri before 8am

Mon-Fri after 4pm

Mon-Fri after 8pm

Saturday

Sunday

Has the client's relevant medical history been communicated, including potential risk situations?

Is there a risk of the client or others at the premises using a weapon?

Does the client have any pets?

Yes

Unkown

If the client has pets, will they be securely locked away during the visit?

Yes

Unknown

Are additional persons expected to be present at the time of the visit?

Yes

Unknown

If there are additional persons expected to be present at the time of the visit, who are they?

Family, Other service provider, Other resident of the property, Not Sure

Are the client / carers aware of the proposed visit?(Required)

Yes

Not yet

Have the client / carers consented to the proposed visit?(Required)

Yes

Not yet

Is the premises easily accessible from the street?

Yes

Is the house visible from the street?

Yes

Is the property remote?

Yes

If the property is remote, please provide specific directions and / or locations so that our clinician may be located easily in an emergency situation.

Attachment(s)

Max. file size: 64 MB.

eg. GP Referral, MH Care Plan, NDIS Plan, Other

How did you hear about us?(Required)

Enquiry

Your enquiry/referral is important to us at LWWHC. Once you submit this form a response will be emailed to you. We will call you if you request a call back. We may need some time to check service(s) availability. We aim to respond within 48 hours of receiving your enquiry/referral. We may phone you if the information needs further verbal clarification. Service(s) availability is 1-2 weeks at this time, once we receive the LWWHC Referral and Intake Form or Consent and any necessary supporting documents for example a GP Referral, MH Care Plan, NDIS Plan. Some forms or documents can be arranged during the initial appointment. If you need a LWWHC service immediately (within 48 hours) please phone us 1300 889 609 to check availability. Alternatively, you can use the Book Now option on this website and we will contact you if any further information is needed to confirm the appointment.

Consent(Required)

I agree to the privacy policy.

I consent for Living Without Worry Health Clinic (LWWHC) to collect, store and utilise this personal information for the purposes of providing services for/to me in accordance with the relevant privacy legislation and any other legal requirements that may apply.

hCaptcha(Required)

Stories of Growth

Discover the impact of our specialised services first hand as individuals share their transformative experiences in the testimonials section, offering insights into the positive outcomes achieved at Living Without Worry Health Clinic.

Living without Worry Clinic provides reliable and highly professional services. With their support, I am back to my social life and on the right track to my mental recovery journey. They support me to increase my NDIS funding, which allows me to have the most appropriate support in my life now.

– Tommy W.
I am extremely happy with the service I have received from Living without Worry Clinic. They understand my situation and support needs with a gentle and warm-hearted approach. Under their professional support, I have dramatically increased my NDIS funding, which better meets my daily mental and physical support needs.

– Jenny W.
I have received friendly, trustworthy and quality services from Living without Worry Clinic. They have improved my mental wellbeing and my life quality as a whole. I highly recommend this service.

– Jacqueline E.

Online Referral Form

Living Without Worry Counselling and Allied Health

If you need assistance completing the form phone us on 1300 889 609

LWWHC Referral and Intake Form

Initial Risk Assessment

Stories of Growth

Living Without Worry Counselling
and Allied Health