REFERRAL FORM
Referrer Information
Details of the person you are referring for a connected supported service to a telehealth clinician.
Name
*
Preferred method of contact
*
Phone
Email
Letter
Best Contact Number
*
Date of Birth
/
Day
/
Month
Year
Date
Do they have a current Mental Health Care Plan
*
Yes
No
If Yes, how many session is the plan supporting
Six (MHCP)
Four (MHCP Review)
10 (COVID Plan)
Please upload a copy of the Mental Health Care Plan
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Referral Information (details of person completing this form)
*
First Name
Last Name
Practice/Organisation & Relationship
*
Best Contact Number
*
Email
*
Reason for Referral
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Supported connection to a clinician
Has the person you are referring to this service been advised you are lodging this form on their behalf for us to connect?
*
Yes
No
MHH Referral Form - Version 1, 2021 review August 2022
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