Referral Form

Thank you for choosing YOU-nique Therapy & Support!

Our dedicated team is passionate about providing individualised, holistic, and family-centred services to support you and your child's therapy journey. By completing this referral form, you are taking an important first step towards accessing personalised support through our innovative All-Through-One (Transdisciplinary) Key Worker model.

Please answer as many questions as you can, providing as much information as possible.

If you have any questions or need assistance completing this form, please don't hesitate to contact our team via mel@you-niquets.com or 0466 715 995.

We look forward to partnering with you on this journey!

Please enter N/A for any questions not relevant.

Child Details

Client First Name *

Preferred Name

Client Last Name *

Client Address *

Suburb *

State *

Postcode *

Client Date of Birth *

Gender *

School/ Early Childhood Service *

Diagnosis (if any) *

Mobile *

Email *

Parent/ Carer Details

Please enter the details for the child's primary caregiver.

Contact First Name *

Contact Last Name *

Relationship to Client *

Contact DOB *

Contact Address

Contact Email *

Contact Mobile *

Child/ Family Cultural Considerations

Funding Details

Do you have NDIS funding?

NDIS Participant Number *

How is your child's plan managed? *

NDIS Plan Start Date/ End Date *

Plan Manager Details i.e. Name/ Organisation, Contact number, Contact email, invoice email *

Referrer Details

Details of individual/ organisation completing Form i.e Name, Email, Contact Number *

Reasons for Referral *

Appointment Preferences

Preferred Days
Mon Tue Wed Thu Fri

Preferred location

Address

Documentation Upload

Please upload any relevant documentation listed below

NDIS plan

Diagnosis letter/ report

Any additional documentation

Where did you hear about our team? *

Thankyou for taking the time to complete this form. We will be in touch soon.