Rainbow Muse Clinic Waitlist

Date of referral

Client Details

Name *

Date of Birth *

Email Address *

Address *

Phone number *

Primary Contact

Name

Phone number

Referral Information

Reason for referral *

Brief History

Please provide NDIS or Funding details if applicable *

Please note: The Medicare Rebate under Mental Health Treatment Plans are not available for Art Therapy and Play Therapy

Preferences

Please give preferred days, times and frequency for appointments. We will provide options to people on the waitlist as these times become available. Some appointments times are more popular than others and make take longer to get availability so the more flexible you are, the sooner we can see you!

PLEASE NOTE: After school appointments have longer wait times, and we have extremely limited weekend options

Preferred time slots on those days *

If outreach to what suburb?

Services

Please indicate the allied health service required. If more than one we will schedule as appropriate.

PLEASE NOTE: WAITLIST FOR PSYCHOLOGY IS CLOSED.

Telehealth Option

Would you be willing to do a telehealth appoinment (we have additional availability for online sessions) *

Referrer details (If filling out on behalf of someone else)

Name

Organisation

Phone

Relationship to client above

Anything else you would like us to know?

Thank you for filling this out!

Signature *

Draw signature|Type signatureClear

Save and Complete Later

We STRONGLY recommend you get on a few waitlists. There is a shortage of allied health supports in both private and public services and waits can often be very long. We cannot guarantee when we will be able to offer supports and encourage people to connect with multiple options to ensure the timeliest support.

We can recommend looking on -https://www.vicinclusivepractitioners.com/websitesor https://polapractice.com.au/therapist-directory for inclusive therapists with availability.

Or you can visit - https://www.anzacata.org/FIND-A-THERAPIST to find a Registered Art Therapist or https://psychology.org.au/find-a-psychologist to find a Psychologist near you.