Referral to Inter Health Services Referral Intake Form Open Form Referral Intake Form – Inter Health Services Section 1: Client Information * Client Details (Required) First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Funding Details NDIS Medicare Private Insurance Number Expiry Date MM DD YYYY Preferred Language Interpreter/Language Support Needed? Yes No Section 2: Service & Funding Funding Type (Select One) * Self Managed Plan Managed Medicare Private Pay Corporate/Workplace Plan manger details 🏥 Services Required (Tick More if Needed) * Therapy & Counselling (NDIS, Private, Medicare, Aged Care) NDIS Functional Capacity & Psychosocial Assessments Positive Behaviour Support (PBS) & Behaviour Plans Workplace & Corporate Mental Health Support Clinical Supervision for Practitioners Aged Care Mental Health & Dementia Support Section 3: Health & Risk Information Diagnosis (If Applicable) Behaviours in the Last 6 Months (Tick all that applied) 🩺 Diagnosis & Behaviours or Special Considerations (Upload document bellow Harm to Self or others Sexualised Behaviour Aggression - Physical or Verbal Wandering 📊 NDIS Behaviour Support Funding Specialist Behaviour Intervention Support (022): Remaining Funds: __________ Behaviour Management Plan & Training (023): Remaining Funds: __________ Urgency Level of Referral Low: Mild verbal abuse, minor property damage requiring clean-up Medium: Physical aggression (not requiring medical attention), verbal abuse (foul language), minor object damage High: Physical aggression requiring first aid, threats of violence, property damage requiring replacement Section 4: Emergency Contact & Referrer Information * 📞 Emergency Contact Details First & Last Name First Name Last Name Phone * Emergency Contact Phone Number (###) ### #### Referrer Information (If Applicable) * First Name Last Name Role * GP Coordinator Self Others Referrer Mobile Phone * Country (###) ### #### Referrer Email Address * Organisation How did you hear about us? Social media Search engine Email newsletter Online ads Blogs or articles Affiliate links Customer review sites Word of Mouth In-person reviews or trade shows Section 5: Consent & Submission * Client / Guardian Declaration: "I consent to my information being provided to Inter Health Services for referral, service delivery, and inclusion in de-identified reporting. Yes No 🖊 Full Name & Digital Signature * First Name Last Name Use Full Name As Signature Yes No Thank you for sending the Referral Intake Form! We have your request and will reach out to the referred client within 24-48 hours. For immediate help, please call 0498 785 225 or email referrals@interhealthservices.com.auThank You Page or Download Referral Form & Email to information@interhealthservices.com.au)Optional: 🔗 Download Referral Form📆 Schedule Your Appointment Now Services Offered Mental health supportDisability assistanceAged care services Referral Highlights Online form for referralsResponse in 24-48 hoursAccepts NDIS, Medicare, private clientsTelehealth, home visits, clinic appointments Who Can Refer? GPs: Medicare MHCP clientsNDIS Coordinators: Assessments/supportAged Care Managers: Mental health evaluationsEmployers: Workplace mental health supportSchools: Counselling services Referral Process Complete and submit online referral form with required documents (MHCP, NDIS Plan, medical reports). We will contact the client within 24-48 hours.For manual referrals, download PDF Referral form and email to Information@interhealthservices.com.au.
