For GPs and allied health practitioners referring a patient for individual therapy or couples counselling. Complete the details below — your email app will open with the referral ready to send.

Patient details

Patient name

Date of birth

Patient phone

Patient email (optional)

Presenting concerns

Anxiety Depression Somatic symptoms ADHD Personality disorder Relationship / couples

Reason for referral / relevant history

Referral & appointment

Mental Health Care Plan in place?

Yes No To be arranged

Preferred appointment type

Individual Couples No preference

Weekday or weekend (Clarity Practice)?

Weekday Weekend Either

Please attach any relevant referral letter or Mental Health Care Plan as a separate file once your email app opens.

Referring practitioner

Your name

Practice name

Practice phone

Your email

Melbourne Dynamic Therapy
880 High Street, Armadale VIC 3143
0451 189 603 · intake@mdt.com.au

Disclaimer

The information provided on this website is intended for general informational purposes only. The content published by Melbourne Dynamic Therapy does not constitute, and should not be construed as, professional therapeutic, psychological, or mental health advice. It is not a substitute for consultation with a qualified mental health professional.

If you are experiencing a mental health concern, we encourage you to seek support from a registered therapist or healthcare provider. In the case of an emergency, please contact 000 or the Lifeline crisis support line on 13 11 14.

We respectfully acknowledge the Traditional Owners and Custodians of the lands on which we work, and pay our respects to Elders past, present and emerging.
Please note that this practice does not offer crisis support or therapeutic services via email or phone.