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Clinician Referral — Continuum Teletherapy and Allied Health

Thank you for referring to Continuum Teletherapy & Allied Health. We'll respond within 1 business day to confirm receipt. For urgent referrals, please also email support@continuumteletherapy.com.au.

This form takes under 2 minutes to complete.

💡 New to Continuum? See our clinician FAQ — including what happens after you refer, whether you'll receive a report back, and our NDIS registration status.

Referring Clinician's Name

Practice Name

Email Address

Best Contact Phone Number

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Contact Number

Is this patient NDIS-funded?

Is this patient NDIS-funded?
A
B
C

Does the patient have a carer, guardian, or support coordinator involved in their care?

Does the patient have a carer, guardian, or support coordinator involved in their care?
A
B

Reason for Referral

Urgency

Urgency guide🟢 RoutinePatient is stable, no immediate risk. Appointment within 4–6 weeks is acceptable.🟡 Within 2 weeksTime-sensitive need but not in crisis. E.g. upcoming NDIS plan review, deteriorating oral health.🔴 UrgentRequires attention within 48–72 hours. E.g. acute pain, patient at risk, NDIS plan about to expire.

Services Requested

Services Requested

Additional Notes (optional)

Consent confirmation

By submitting this form, you confirm that you have obtained the patient's (or their guardian's) verbal or written consent to share their information with Continuum Teletherapy & Allied Health for the purpose of coordinating care. Information is handled in accordance with our Privacy Policy and the Australian Privacy Principles.
Consent confirmation