- Referral – Online Form -

HelloDoc Referral Form

"*" indicates required fields

Referrer is a:

General Practitioner

Nurse Practitioner

Other

Name:*

Practice Name:*

Practice Email/Fax (Preferred way of communication):*

Address:*

Postcode:

Phone:

Provider No.:

Referral date:

First Name:*

Surname:*

Date Of Birth

Address:*

Postcode:

Phone:

Email:

Medicare Card (Medicare card & Ref no.):

Next of Kin, Contact No. and Name:

Psychiatric assessment under 291

Private patient/ non-Medicare card holder

Review appointment for existing patient (MBS 293 or other relevant item number)

Details for referral:

Past psychiatric history (including hospital admissions):

Medications:

Risk concerns: (eg. suicidal ideation, past suicidal attempts, self-harm, forensic / police involvement, violence)

Attach Document (Referral Attachement)

Accepted file types: jpg, jpeg, png, gif, webp, avif, bmp, svg, heic, heif, Max. file size: 20 MB.