White Cloud Tele-Mental Health Professional Referral Form

Thank you for considering the White Cloud Tele-Mental Health Service.

The following form is to be completed in order to refer a client to the White Cloud Tele-Mental Health Service. Once referred, we will be in touch with the client to set up an initial intake appointment.

If you’re client is aged between 12-18 years, please call White Cloud direct on 07 3155 3456 to book them an appointment. Online referrals are not accepted for this age group.

Please note that our focus is on early intervention for mild to moderate mental health symptoms. We provide a multidisciplinary service, utilising Social Work, Psychology, Counselling, Dietetics and Exercise Physiology input.

White Cloud Tele-Mental Health does not provide long-term community mental health support. We provide short-term intervention (approximately 5-6 appointments).

We may not be the appropriate service for your client if they have acute or chronic mental health conditions such as:

• A personality related diagnosis
• PTSD
• Eating disorder
• Psychosis/ mania
• Complex trauma
• Limited cognitive capacity

To help us ensure your client is suitable for the White Cloud Tele-Mental Health Service, please answer the following questions.

What is the main reason/s you are referring this client? *

• Grief/loss
• Symptoms of depression
• Symptoms of anxiety
• Relationship/family issues
• Coping with change
• Financial hardship
• Homelessness
• Improving wellness
• Managing stress
• Other

If other, please specify:

Is there evidence that the client has active suicidal ideation? *Please selectYesNo

If yes, please refer your client to the nearest crisis care provider as White Cloud Tele-Mental Health is not a crisis support service.

Client Details

Name *

First

Last

Date of Birth *

Please note, if the client is aged between 12-18 years, they cannot be referred through this form. For clients aged 12-18 years, you must call White Cloud direct on 07 3155 3456 to book an appointment.

Phone *

Email

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Does the client identify as a First Nations' person? *Please selectYesNoUnknown

Referrer Details

Name *

First

Last

Where do you work? (Please provide name of hospital/facility/organisation) *

What is your position/role? *

Email *

Phone *

Consent

Has the client consented to this referral? *Please selectYesNo

Has the client consented for us to keep you updated on their treatment? *Please selectYesNoNot required

Other Information

Is there anything else we should know?

By submitting this referral you agree to us processing this information in line with White Cloud Foundation's Privacy Policy. *

• I understand and agree with the WCF Privacy Policy.

To read White Cloud Foundation’s Privacy Policy visit: https://whitecloudfoundation.org/privacy-policy

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