Referral Form

Referrer Details
REFERRER IS A:

General Practitioner	Nurse Practitioner

Others

PRACTICE EMAIL/FAX :  (PREFERRED WAY OF COMMUNICATION):	ADDRESS:

POSTCODE :

PHONE :

PROVIDER NO. :

REFERRAL DATE:

Referrer Details
FIRST NAME:

SURNAME:

DATE OF BIRTH:

ADDRESS:

POSTCODE :

PHONE :

EMAIL (PREFERRED):

MEDICARE CARD (MEDICARE CARD & REF NO.):

NAME:	PRACTICE NAME:
NEXT OF KIN, CONTACT NO. AND NAME:

REASON FOR REFERRAL:
   PSYCHIATRIC ASSESSMENT UNDER 291   PSYCHIATRIST ONGOING APPOINTMENTS OR 291
PRIVATE PATIENT/ NON-MEDICARE CARD HOLDER
REVIEW APPOINTMENT FOR EXISTING PATIENT (MBS 293 OR OTHER RELEVANT ITEM NUMBER)

DETAILS FOR REFERRAL:

MEDICATIONS:

RISK CONCERNS:

Please send any additional supportive documents along with this letter

PAST PSYCHIATRIC HISTORY (INCLUDING HOSPITAL ADMISSIONS):

*PLEASE ADVISE YOUR PATIENTS TO CALL US IF THEY HAVE NOT HEARD FROM US WITHIN 5 BUSINESS DAYS OF SENDING THE REFERRAL