Name *

First Name

Last Name

Phone *

(###)

###

####

Name of support person *

First Name

Last Name

Phone number of support person *

(###)

###

####

Will a GP Mental Health Care Plan be following this referral? *

Yes

No

Do you have a preference to see a male or female psychologist? *

Male

Female

I don't have a preference

Which of our locations does your enquiry refer to? *

Launceston

Devonport

Telehealth

Please tick the following boxes that apply. *

Trauma and PTSD

Anxiety and panic attacks

Pain management

School refusal

Addiction

Relationship issues

Eating disorders

Depression

Bariatric surgery

Phobias

Self harming thoughts and behaviours

Assessment for ADHD, Autism or Learning difficulties (please state below if known)

Other