Psychology Clinic Enquiry Form

This form is for internal use only and will not substitute for a Mental Health Plan, DVA Referral or other forms of approval.

Patient Full Name *

Patient Phone Number *

Patient DOB *

MRN

Primary Diagnosis *

Secondary Diagnosis

Funding *

Appointment Type *

Face to FaceTelehealth ONLY

Available Psychologist - TELEHEALTH ONLY *

First Available Psychologist Kerry Searle - Psych - Anxiety/Mood, Bipolar, BPD, Parents, Psychosis, Trauma, LGBTIQI, Neurodivergent Pres (CBT/DBT, EMDR, IPT)Zachary Churchill - Psych - Anxiety, OCD, Trauma, BPD, Addictions (CBT, DBT, ACT, Psychodynamic)Ashleigh Wesseling - Psych - Mood, Anxiety, Addictions, Personality Disorders, Trauma (CBT, DBT, ACT, EMDR)Lauren Gow - Psych - Trauma, Mood, Anxiety, Adjustment Disorder (CBT, DBT, TF-CBT, ACT, EMDR)Luke Smith - Psych - Anxiety, Mood, Trauma, Personality, ADHD (CBT, DBT, TF-CBT, ACT, IFS-Informed, EMDR)Tiana Sparacino – Psych – Trauma, personality/relational, anxiety and mood (ACT/CBT/DBT, Schema Therapy, IFS, Psychodynamic)Adele Cave - Psych - Anxiety, Mood, ADHD, Sleep, Cognitive Decline (CBT, DBT, ACT)

For further information regarding our Psychologists please see our website linked below

Outpatient Psychology Clinic | South Coast Private Hospital

Comments

Dr Name *

Dr Signature *

Draw signature|Type signatureClear

Date of Referral *

Dr Email address *