Albury Cognitive Clinic

New Referrals Form

Referral forms can be completed by individuals, treating health professionals, support coordinators, or other representatives.

We endeavour to respond to referrals within 5-10 business days. We will advise of current wait times at the time of referral acceptance.

    Client Details






    Date of Birth










    (if relevant)



    (if relevant)

    Plan-managedSelf-managed




    Contact Persons Details










    Referrer Details






     

    Payment Method

    Self Funded

    NDIS

    Third party


     

    Existing Diagnoses and Conditions

    Please advise of existing diagnoses and conditions using the options below. Please provide details below.

    Cognitive delay/condition (e.g., memory difficulties, slow processing)

    Psychological conditions (e.g., depression, anxiety, OCD)

    Neurodevelopmental diagnoses (e.g., Autism, ADHD, Intellectual Disability)

    Genetic conditions (e.g., Down syndrome, Fragile X)

    Physiological (e.g., hearing, eyesight, movement)

    Medical conditions

    Details of existing conditions; please also include any allergies


     

    Reason for Referral

    Assessment

    Please advise the purpose of the assessment; what would you like to be addressed? Please include additional information below.

    Cognitive and/or Memory Concerns

    Decision Making Capacity: (Guardianship, Power of Attorney)

    Psychological Concerns

    Neurodevelopmental Conditions (e.g., Autism, ADHD, Learning Difficulties, Intellectual Disability)


     


     

    Therapy

    Please advise the purpose of therapy; what would you like to be addressed? Please include additional information below.