Contact

Contact

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First Name:

Last Name:

Contact Number:

Contact Email:

Client Name:

Client Age:

Aboriginal/Torres Strait Islander?

Reason for Referral

Symptoms of concern

Previous/Current Diagnoses (if known)

Previous psychological/psychiatric support

Goals for treatment

Is the client involved with other services?

Do you have a GP Mental Health Care Plan?

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Do you have a NDIS plan?

If so, please fill out this section, if not please select 'I do not have a NDIS plan' and move onto the next section.

NDIS number:

Plan manager:

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Do you have a WorkCover/SIRA/CTP funded claim?

If so, please fill out this section, if not please select 'no' and submit the form. Thank you.

Claim number:

Insurer:

Case manager:

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Fees for Service

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I understand that services are not Bulk Billed and there are fees related to all services at The PaC Group.

Phone: 0422 751 794

Email: admin@thepacgroup.com.au

Address: 50 Bultje Street, Dubbo NSW 2830