Gidget Third Party Referral Form

This information will be valuable in supplementing your client’s case information. It will only be reviewed and actioned by Gidget Foundation Australia (GFA) upon receipt of a GP Referral and Mental Health Care Plan.
Organisation or Hospital Name*
Information provided By*

MidwifePIMHSOBGYNSocial WorkersTresillian servicesKaritane ServicesChild & Family Health servicesOther
Gidget Foundation Australia clinicians offer individual and group perinatal psychological counselling. The eligibility questions below will assist your client in accessing the most suitable care for their current situation.
My client is currently experiencing, and does not have additional specialised support in place for (please tick any relevant boxes)*

Current or enduring psychotic illnessCurrent serious suicidal, homicidal or infanticidal ideationCurrent child protection and/or family violence or issues requiring Department of Communities and Justice involvementCurrent serious substance abuse that requires medical interventionIs NOT experiencing any of the above
Unfortunately, your client falls outside our eligibility criteria. If you still feel we are an appropriate service for them please explain why below.
Client Name*

First NameLast Name
Gender*
Date Of Birth*

MonthDayYear
Date
Mobile Number*
In order for our system to correctly send a notification to the patient, please leave off the 0 from the beginning of the number and start after the first 4 noted above.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Perinatal Status*

AntenatalPostnatalLoss
Expected Due Date*

MonthDayYear
Date
Important Note: Baby must be under 12 months at time of this referral
Baby's Birth Date

MonthDayYear
Date
To help us deliver the best possible care, please provide the reason for referral. *
Any Relevant Attachments

Cancelof
I have advised my client that the free service available through GFA requires a GP referral and Mental Health Care Plan.
I have informed my client that should they wish to proceed with GFA services, they will need to see their GP and that this information will only be used in conjunction with what their GP provides.
My client is aware that the above information has been provided and GFA may communicate back to the person completing this form about their progress.
Following submission of this form, your client will receive a text with a link to the GFA GP Referral and Plan for when they visit their GP, should they choose to proceed with the referral.
Referrer's Signature

Clear
Date

MonthDayYear
Date
Referrer's Email
example@example.com
Important Note: By providing your email address you will receive two emails. The first email contains a password to access the second email to ensure client privacy. The second email will contain a copy of this form for your records, accessible using the password.
Should be Empty: