Employee Assistance Program Form

Client Name*
First Last
Client Address*
Street Address City State Postcode Country
Phone Number*
Email*
Date of Birth

DD
MM
YYYY
Medicare Number
Health Care Number
Insurer
Claim Number
Employer
Reason for Referral
- Anger
- Depression
- Anxiety
- Grief / Loss
- Stress
- Pain Management
- Relationship Difficulties
- Other Personal Concern
- Work Concern
Please specify the concern
Special Requirements / Additional Information
Referral
(including Mental Health Care Plan or WorkCover Certificate)
Preferred Location
Referrers Details
Referring Doctor / Professional
Prefix First Last
Phone Number
How did you hear about AusPsych?*