Private Clients referral.

Self-funded clients paying directly for services.

Who is completing this form?

Client Information

Client's Full Name*

Client's Date of Birth*

Client's Gender

Client's Medicare Number

Client's Phone*

Client's Email*

Client's Address

Used for billing purposes. If not provided we'll confirm at intake.

Services Requested

What services is the client interested in?*

Clinical Information

Please send any relevant medical information to admin@healthsocietyco.com.au

Client's Primary Diagnosis*

Reason for Referral*

Client's Goals*

Relevant Medical History / Attached Reports

Other treating practitioners, previous therapy, surgical history. Note any attached reports.

Availability for Clinic Appointments*

Recommended Treatment Frequency*

Contact to Book the Appointment*

If someone other than the client manages their clinic bookings (e.g. carer, support coordinator, family member), please provide their name and number.

Referring Practitioner

Practitioner's Full Name*

Role / Profession*

Practice / Organisation

Provider Number

Referrer's Phone*

Referrer's Email*

Additional Information

Cultural or Additional Information

How did you hear about Health Society Co.?*

Your information is transmitted securely and handled in accordance with our Privacy Policy.

By submitting this form you confirm you have the client's consent to share their information with Health Society Co.