PSYCH ASSIST REFERRAL

Submit a Referral to Psych Assist

Injured Worker
Full Name:		Street:
Phone:		Suburb:
Date of Birth:		State:
Interpreter Lang:		Postcode:
Occupation:		Work Status:
Injury Details
Type of Injury (s):		Date of Injury:
Selected Duties:		Claim Number:
Employer
Employer:		Street:
Phone:		Suburb:
Fax:		State:
E-mail:		Postcode:
Supervisor:		RTW Coordinator:
Agent
Insurer:		Street:
Phone:		Suburb:
Fax:		State:
E-mail:		Postcode:
Contact:		Liability Status:
Treating Doctor
Full Name:		Street:
Phone:		Suburb:
Fax:		State:
E-mail:		Postcode:
Reason for Referral
Pain Management Counselling		Adjustment & Disability Counselling
Motivational Counselling		Counselling for Anxiety & Depression
Education Regarding Psychological Treatment		Mediation Services
Pre-Liability (Stress) Assessment		Critical Incident Debriefing
Psychological Clearance for Work		Online Pre-Placement Psych Screening
EAP (Employee Assistance Program)		Other
Comments:
Referrer
Name/Company:		E-mail:
Approval Status for Injury Management Services
Insurer Approval:		Preferred Office