Nazia Wasif
Referring Person's Information
Full Name: Relationship to Client: Phone Number: Email Address: Preferred Contact Method: EmailPhone
Client's Information
Full Name: Date of Birth: Age: Gender: MaleFemaleOtherPrefer not to say Address: Cleint’s Phone Number (If applicable): Primary Language: Is an interpreter needed? YesNO
NDIS or Private Client Information
Is the client an NDIS participant? YesNo
Diagnosis Information
Has the client been diagnosed with any medical, psychological, or developmental conditions? YesNoIf yes, please provide the diagnosis or conditions: If yes, please provide the NDIS number:
NDIS Plan Type
Payment Information
Please select the payment option that applies to you: NDIS Self-ManagedNDIS Plan-ManagedMedicare Referral (GP or Paediatrician referral, MHCP, EPC)Third Party (VOCAT, DHHS, TAC, Other)Privately Paying If other, please specify:
Reason for Referral
Please describe the primary reason for referring the client to art therapy:
Presenting Concerns (Check all that apply) AnxietyDepressionTraumaGrief and LossBehavioral IssuesSelf-EsteemCommunication DifficultiesEmotional RegulationStress ManagementSocial SkillsLearning DifficultiesDisability-Related ConcernsOther Please specify:
Additional Information
Any specific behaviors or triggers to be aware of during therapy sessions? Are there any medical conditions, disabilities, or special needs to consider? YesNo If yes, please specify: Is the client currently receiving any other support services (e.g., OT, Speech Therapy, Counseling)? YesNo If yes, please specify:
Emergency Contact Information
Emergency Contact Name: Relationship to Client: Emergency Contact Phone Number: Additional Comments or Information:
