Download Referral form for Psychology Clinic

REFERRAL TO CHILD AND ADOLESCENT
PSYCHOLOGY CLINIC
Black Dog Institute
Hospital Road
Prince of Wales Hospital
Randwick NSW 2031
Tel: (02) 9382 2991
Fax: (02) 9382 8510
[email protected]
Supported by NSW Health
Date:__________________________________
REFERRING DOCTOR DETAILS:
Please attach a copy of the practice letterhead & the Mental Health Care Plan with this referral
NAME:
……………………………………………….
PROVIDER NUMBER:
……………………………………………….
PRACTICE ADDRESS:
……………………………………………….
……………………………………………….
Telephone Number:
……………………………………………….
Facsimile Number:
……………………………………………….
DOCTOR’s SIGNATURE:
………………………………………………
PATIENT CONTACT DETAILS:
FULL NAME (First and Family Name): ……………………………………………….
DATE OF BIRTH:
……………………………………………….
HOME ADDRESS:
……………………………………………….
……………………………………………….
……………………………………………….
CONTACT DETAILS:
Home Tel:
……………………………………………….
Mobile:
……………………………………………….
Email Address: ……………………………………………….
IS THE PATIENT:
Pensioner
IS THE REFERRAL FOR:
Australian student
Individual therapy
International student
Group therapy
Both
HAS THE PATIENT COMPLETED THE MAP (Mood Assessment Program)?
Yes
(Please attach report with Mental Health Care Plan)
No
Referring doctors please note that the Black Dog Institute will provide assessment and psychological
treatment plan but will not provide crisis management at the point of referral.
REASON FOR REFERRAL
PROVISIONAL DIAGNOSIS AND
COMORBIDITIES (IF ANY)
CURRENT MEDICATIONS /
EFFECTIVENESS
PAST MEDICATIONS /
EFFECTIVENESS
RECENT PSYCHOLOGICAL
INTERVENTIONS
OTHER CURRENT THERAPISTS
PAST DIAGNOSES
RELEVANT MEDICAL/
PSYCHIATRIC HISTORY
RELEVANT FAMILY MEDICAL
HISTORY
VALID FOR
On completion, please fax this referral, together with your
Mental Health Care Plan to (02) 9382-8510 – Psychology Clinic,
Black Dog Institute.
We cannot book an appointment until when we receive both the
MHCP and the referral