Third Party Referral Form - Myrtle Oak Clinic

Use this form to refer a client to Myrtle Oak Clinic for specialised eating disorder and mental health support. Whether you are a case manager, organisation or third-party provider, this referral process allows our team to gather the key information needed to arrange an initial assessment and begin planning appropriate care. Our clinicians take a collaborative and personalised approach to support each client’s needs from the very first appointment.

Client name

Date of birth

Address

Phone

Emergency contact

Emergency contact number

Relationship to client

Who shall we contact to book the initial assessment?

Name

Phone

Relationship to client

Case Manager

Case manager name

Organisation and role

Case manager phone

Case manager email

Main reason for referral to Dietitian or Psychologist:

Invoicing Details:

Which office/department/organisation is responsible for payment of services?:

Organisation

Claim number

Approval number (if relevant)

Invoice to be sent to email

Initial Assesment

The initial evaluation enables the clinician to conduct a comprehensive assessment, engage in goal discussions, and establish a future plan. Following the initial assessment, a report outlining suggested interventions and associated costs will be sent to you for review. We will not proceed with any additional services until we receive your written approval, which you can provide by signing the final page of the report.

Initial Assessment and Report:
DietitianPsychologist

Where should the report be sent to? Email

Do you require a formal quote on letterhead before proceeding with the initial appointment?
YesNo

Does this person have a GP referral?

YesNo

What is the name of the GP?

Practice name

If so, do they also have a care plan (Chronic Disease Management Plan, Mental Heatlh Care Plan or Eating Disorder Plan)

Does this client have an NDIS Plan?
YesNo

Any additional information to assist with proceeding with assessment and /or treatment? Any safety issues present?

*Service Fee as of July 2025 - subject to change as required:

NOTE- these fees are provided for informaiton purposees only. Subsequent sessions following the initial assessment will be detailed and costed in the initial report, and further services will not be provided until signed approval received.

Clinic Based Initial Assessment (includes report): Dietitian $425 | Psychology $425

Form Completed by:

Name

Position

Organisation

Phone

Date