Interested in Therapy?

Pola Practice prides itself in providing culturally responsive care. As such, we have a process to ensure you are matched with the right clinician for you. The process includes the following steps:

Referral:
- Completing the self-referral form so we can book you in for an intake appointment
Intake Appointment and Allocations:
- We conduct an initial intake assessment, this is a 60 min (individual) to 90 mins (couples/families) session with an Intake clinician.
- This session costs $100 for individuals and $150 for couples/dyads and can be done in person or via Telehealth.
- You are matched with a therapist based on your needs and our availability/capacity and/ or made recommendations with any additional referrals.
Begin:
- You begin therapy and/or referred to support services

Self-Referral Form

Consent and Confidentiality

The information gathered below is for the purpose of providing you with the best service. It is stored under confidentiality and would not be accessed for any other purposes.

Name

First Name

Last Name

Date of Birth (dd/mm/yy)

Pronouns

Phone

Mobile number - make sure its all 10 digits

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact

Please include their name, best contact details, and relationship to you.

Client Status

If you are a new client you will need to attend "Intake Appointment" , during which an intake clinician will assess your needs. You will then be matched with the appropriate Therapist or we can support you by making external referrals to external services.

Intake Preferred Day

Please note intake occurs between Monday to Friday. Please provide three options for a day.

Intake Preferred Times

Note that all intakes occur during business hours: Please provide three options for a time.

Preferred Intake location

Intake can occur online or in person at our Ascot Vale location. Please detail if you have a preference.

Intake Clinician Preferences

Note down any preferences regarding your intake clinician eg: gender of the therapist. Please note that your intake clinician may not be your final therapist, instead they are the person who does the initial assessment

Reason for your referral to Pola Practice

*If this is a family therapy referral, note down number of family members who will attend the session

Therapist preference (may differ from intake clinicians)

Who is your prefered therapist, once you begin therapy with us? Read the bios of our therapists before choosing.

Interested in Therapy?

Self-Referral Form

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Pola Practice