Gidget Foundation Hospital In-Patient Assessment Form

In-Patient Assessment Form

Gidget Foundation Australia
Gidget Foundation Australia (GFA) supports the mental health of expectant, new and potential parents.

The GFA In-Patient Assessment service is offered to patients identified by their Health Professional as benefiting from an assessment with a GFA Clinician. This one-off assessment session can only take place while the patient is under the care of the hospital.

Make note of this email address: clinicalintake@gidgetfoundation.org.au. We welcome you to connect with us to follow up on the next steps for your patient or if you are unable to access the copy of your referral after submission.

Important Note: Baby must be under 12 months at time of this referral
Name of Hospital*
Date*

DayMonthYear
Name of hospital staff member completing this referral*
Designation of hospital staff member completing this referral*
Contact number of hospital (ward, maternity unit manager)*
Please enter a valid phone number.Format: (00) 0000-0000.
Patient Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Birth*

DayMonthYear
Date
Email*
example@example.com
Mobile Number*
Please enter using the format aboveFormat: 0400-000-000.
AntenatalPostnatalLoss
Expected Due Date*

DayMonthYear
Date
Baby's Birth Date

DayMonthYear
Date
To help us deliver the best possible care, please provide the reason for referral.*
Patient General Practitioner
Clinic Name*
GP Name*

First NameLast Name
GP Phone Number*
Please enter a valid phone number.Format: (00) 0000-0000.
Patient Emergency Contact
Full Name*

First NameLast Name
Relationship*
Mobile Number*
Please enter a valid phone number.Format: 0400-000-000.
Email
example@example.com
Patient Other Support
YesNo
Name and Details
YesNo
Name and Details:
The patient has provided verbal consent for the staff member to complete this form on their behalf and for the content contained within this form to be shared with GFA. The patient is also aware that GFA may communicate back to the person completing this form about their progress.
The patient has provided verbal consent for a one-off consultation to be provided by a GFA clinician.
The patient has been informed that their emergency contact and/or supporting health professionals detailed within this referral form may be contacted by the GFA clinician in relation to the patient’s treatment.
Following submission of this form, your patient will be contacted by our Clinical Intake Coordinators.
Referrer's Signature*
Date*

DayMonthYear
Date
Referrer's Email*
example@example.com
Referrer's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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:

In-Patient Assessment Form

Patient Information

Patient General Practitioner

Patient Emergency Contact

Patient Other Support