Telepsychiatry Referral Form

This referral is only valid with a unique referral code obtained from WHL intake line. 
To obtain a code please phone 1800 223 365.

UNIQUE REFERRAL CODE: 	DATE OF REFERRAL: <TodaysDate>	
GP DETAILS	
Name: <DrName>	Practice name: <Practice>	
Practice phone: <DrPhone>	HealthLink EDI: 	
PATIENT DETAILS	
Name: <PtName>	DOB: <PtDoB>	
Healthcare card number:                                            	Expiry date:	
Medicare number: <PtMCNo>	Ref #: <PtMCLine>	Expiry date: <PtMCExpiry>	
Known mental health diagnosis (Primary): 	
Known mental health diagnosis (Secondary):	
Medications: 
<RegularRx>	
Has the patient experienced a recent history of self-harm, suicide attempt or were thoughts of suicide or self-harm a factor in obtaining this referral     YES   /   NO	
Labour force participation:  Employed    /   Unemployed looking for work    /   Unemployed	
Patient income: <16 years old    /    Paid employment   /    Disability Support   /   Other pension   /   Nil	
Relationship status: <PtMaritalSt>	
KEY SUPPORTS:  Patient has given consent to contact support person:  YES  /   NO	
Name:		Phone: 	
Relationship to patient:		
OTHER MENTAL HEALTH PROFESSIONALS CURRENTLY INVOLVED IN PATIENTS CARE	
Name:	Phone:	
Name:		Phone:	
Patient has given consent to contact  YES  /  NO	
REASON FOR REFERRAL	

	
ADDITIONAL REFERRAL NOTES	

Patient Consent: By consenting to this referral, I understand that all information in this referral, and any previous referrals (where applicable) including my personal information, will be collected for the primary purpose of delivering care; and for the ongoing monitoring, reporting, evaluation, and improvement of services. I consent with the understanding that this information will only be used, disclosed, and stored for its primary purpose, between my health service provider(s), the Department of Health, and the Nepean Blue Mountains Primary Health Network (NBMPHN) and affiliated partner organisation(s)*, in accordance with the Australian Government Privacy Act, 1988.
* Affiliated partner organisation(s) means those required to support the monitoring, reporting, evaluation and/or clinical governance for the service.

Patient Signature:	Date: <TodaysDate>	

Consent for children and young people:
Parent/Guardian/Carer Name: 		
Contact number:	Email: 	
Signature 	Date 	
Patient, or guardian has given informed verbal consent on (date):	

GP STAMP OR SIGANTURE AND DATE 	

	
PLEASE ENSURE THE FOLLOWING STEPS ARE FOLLWED BEFORE SENDING TO DOKOTELA 	
¨ This referral form is complete. 
¨ A unique referral code has been obtained from WHL intake 1800 223 365
¨ A current K-10 or K-5 (suitable for Aboriginal and Torres Strait Islander People has been completed and is attached to this referral, or, for children and adolescents between 4-17, a current, age-appropriate version of the SDQ has been completed and is attached to this referral. 
¨ There is a current mental heath treatment plan that has been attached to this referral. 	

Please send completed referral form and attachments to DOKOTELA Pty Ltd
HealthLink EDI: Dokotela
Secure Fax: (02) 8569 1844