Online Referrals

The online referral form below is designed for health and legal professionals. If you are a client and would like to self-refer, please book an appointment online, call PsyAx on 1300 455 677 or visit the contact us page for more options.

Book Appointment

Privacy

In the referral form below, we ask for information about yourself, your client, and their support person. We need this information to know how to respond to your referral. Any information you provide to us will be treated in accordance with the Australian Privacy Principles.

Submit an Online Referral

As a security measure, we use HTTPS encryption across the entire PsyAx website. This means that any information you submit to us online is encrypted to protect your privacy and your client's privacy.

CLIENT DETAILS

* Indicates required field

Client name *

First

Last

Client date of birth (dd/mm/yyyy) *

Has the client consented to the referral? *

Yes, they have consented. No, they have not consented. It is unclear whether they can consent.

Client phone number (optional) *

Client email address (optional) *

SUPPORT PERSON

Is the appointment to be organised through a support person? *

Yes, please contact the support person to arrange No, please contact the client directly

Support Person name *

First

Last

What is their relationship to the client? *

Support Person phone number *

Support Person email address *

Referrer Details

Referrer name *

First

Last

Organisation *

Referrer email address *

Referrer phone number *

Upload referral letter (optional) *

Max file size: 20MB

Brief notes on referral *

Send