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Fortify Health Group

Allied Health Referral Form

Fortify Health Group provides a wide range of supports, including allied health, NDIS services and Multicultural Mental Health.

Allied Health Referral form

Fill in The Form Below

If you are an NDIS participant, please complete THIS form instead.

 

If you are looking for our free Multicultural Mental Health services, please complete THIS form instead.

 

A GP referral is required for Psychiatry and should not be submitted through this form. Please send referrals direct to info@fortifyhealth.com.au, through Medical Objects, or via fax to 07 3523 3717.

Do you consent (or where the referral is made by a third party, has the individual consented) to this referral?
Full name
Date of birth
Gender ? Gender identity is the personal sense of one’s own gender. Gender identity can correlate with assigned sex at birth or can differ from it. Gender categories can serve as the basis of the formation of a person’s social identity in relation to other members of society.
Address
Do you require an interpreter?
To help us meet our ethical obligations and provide the best care, please let us know if any family members are also using our services. This helps us avoid conflicts of interest and ensures that each person receives unbiased and dedicated attention.
Do you have any family members who are also receiving services through Fortify Health Group?
If yes, please provide their name, relationship to you and the service they are currently receiving.
What services do you need? (tick all that apply)
Reason for referral - please provide some information about your needs to assist us with matching you with the right practitioner.
Do you have a Mental Health Care Plan, or a Chronic Disease Management Plan?
How did you hear about our services?
Please note, if you press 'Submit' and the page does not change there is likely a field incomplete above. Please do not refresh the page, as this will remove your entry, scroll up to find the incomplete section marked in RED.

If there are no RED sections please make sure that all fields under 'Emergency contacts' and 'Guardian/Nominee' are completed (or put N/A), as only partially filling these fields means that the form will not submit.