Refer online

Are you self-referring or referring someone else?

You will need consent from the person you are referring if referring someone else.

1. Your Details

Title

First name*

Last name*

Select your region*

Address*

Street Address Address Line 2 Suburb State Postcode

Are you homeless?

Phone (Home)

Phone (Mobile)*

Email*

DOB*

Gender

Country of birth

Are you Aboriginal or Torres Strait Islander?

Do you require an interpreter?

For which language do you require an interpreter?

2. Next of Kin

Next of Kin Name

Relationship

Phone

3. Current General Practitioner

GP Name

Practice

Phone

4. Support

Have you applied to the NDIS?*

What was the outcome?

5. Psychosocial (non-clinical) Needs and Mental Health Concerns

Past/Present diagnosis of mental health condition, if any:

Last Hospital Admission (due to mental illness), if any:

To what extent does your mental health condition impact on your everyday life (frequency, social, personal or work life etc)?

Please tick which psychosocial areas you would like to work on

Friendships, social skills and family connection
Education and training goals
Finding and maintaining a home
Vocational skills and finding a job
Managing daily living needs
Physical wellbeing and exercise
Financial management and budgeting
Building life skills including confidence and resilience
Other (specify)

Other

Please list any current mental health professionals or mental health programs you are currently receiving support from:

6. Consent

I consent to this referral and I agree to information about my mental health being recorded in my medical file and shared between the GP, South Western Sydney PHN Central Intake to assist in the management of my health care and the Mental Health Professional to whom I am referred.*

Yes

I consent to receive this service, and for sharing of service delivery information*

Yes
No

I consent to sharing my de-identified data (no identifiable information) with Department of Health and Aged Care*

Yes
No

I consent to being sent an experience of service survey*

Yes
No

I understand that SWSPHN will provide information that does not identify me, such as the types of service I receive, to the Department of Health to assist improvement of mental health services in Australia and consent to the sharing of this information with the Department of Health.

Yes

1. Referrer details

Name*

Organisation

Position

Phone*

Fax

Email*

Suburb

Relationship to consumer*

2. Consumer details

Title

First name*

Last name*

Select applicable region*

Address*

Street Address Address Line 2 Suburb State Postcode

Is the consumer homeless?

Phone (Home)

Phone (Mobile)*

Email

DOB*

Gender

Country of birth

Is the consumer Aboriginal or Torres Strait Islander?

Is an interpreter required?

For which language is an interpreter required?

3. Next of Kin

Next of Kin Name

Relationship

Phone

4. Current General Practitioner (GP)

GP Name

Practice

Phone

5. Support

Has the consumer applied to the NDIS?*

What was the outcome?

6. Psychosocial (non-clinical) Needs and Mental Health Concerns

Past/Present diagnosis of mental health condition, if any:

Last Hospital Admission (due to mental illness), if any:

To what extent does their mental health condition impact on their everyday life (frequency, social, personal or work life etc)?

Please tick which psychosocial areas they would like to work on

Education and training goals
Finding and maintaining a home
Vocational skills and finding a job
Managing daily living needs
Physical wellbeing and exercise
Financial management and budgeting
Building life skills including confidence and resilience
Other (specify)

Other

Please list any current mental health professionals or mental health programs the consumer is currently receiving support from:

7. Consent

Has the person that you are referring consented to the referral being made?*

Yes

Client consents to receive this service, and for sharing of service delivery information.*

Yes
No

Client consents to share their de-identified data (no identifiable information)with Department of Health and Aged Care*

Yes
No

Client consents to being sent an experience of service survey*

Yes
No

I understand that SWSPHN will provide information that does not identify anyone, such as the types of service received, to the Department of Health to assist improvement of mental health services in Australia and consent to the sharing of this information with the Department of Health.

Yes

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Refer Online

1. Your Details

2. Next of Kin

3. Current General Practitioner

4. Support

5. Psychosocial (non-clinical) Needs and Mental Health Concerns

6. Consent

1. Referrer details

2. Consumer details

3. Next of Kin

4. Current General Practitioner (GP)

5. Support

6. Psychosocial (non-clinical) Needs and Mental Health Concerns

7. Consent