The Discovery Space Referral Form

Referring Clinician Details

Full name

Profession/Role

Organisation

Contact Number

Client Details

Full Name

Preferred Name (optional)

Date of Birth

Contact Number

Location

Presenting Issue (Brief Overview)

Please provide a short summary of the client's reason for referral, including any relevant psychosexual concerns (e.g. low libido, painful sex, difficulty orgasming, self-esteem concerns, etc.):

Relevant History (if known)

Mental Health diagnosis or concerns

Physical health concerns (e.g. chronic pain, hormonal issues, past surgeries)

Medications

Known trauma history (if clinically relevant and with consent)

Current supports (e.g. GP, psychiatrist, pelvic physio, etc.)

Goals of Therapy

What would the client ideally like support with?

Additional Notes

E.g. interpreter required, disability access, cultural identity, gender identity, sensory needs, or other relevant info

Consent

Please confirm:

The client has consented to the referral and is aware their information will be shared.

Signature & Date

Signature (typed name):

Date:

Upload Referral Letter (Optional)

If you have a referral letter, you can upload it here.