Mind Body Innovation Centre Referral Form

ph: 02 4086 7141 | fx: 02 4989 6955
ad: Level 1, Suite 1 / 21 Annie St, Wickham NSW 2293
wb: mbicentre.com.au
em: hello@mbicentre.com.au

Mind Body Innovation Centre is a integrated mental health service focused on improving patient outcomes

•We can only engage with people who have provided consent to the referral.

If the person is at high or acute risk of suicide, please contact the Mental Health Line on 1800 011 511 or emergency services on 000 if urgent.

• Please note that receipt of the referral form does not indicate acceptance to the headspace services.

Suitability of the referral will be determined following assessment with the person referred.

Please contact Mind Body Inovation Centre sould you wish to discuss suitability prior to referring on (02) 4086 7141 or hello@mbicentre.com.au

• To complete the referral, please attach relevant assessment notes, discharge summaries and/or additional information

A note for your convenience

If all the relavent information is already captured in a document please fill out the 'Consent' and 'Referral Information' sections only.

Date of Referral*

Date

Has the person given consent for the referral?*

YesNo

Is there a Mental Health Care Plan?*

YesNo

Is this referral for another funding model?*

YesNo

Please specify funding model*

Has the person’s parents consented to the referral?*

YesNoThey 16 years or older - (Not applicable)

The parents are aware that they will need to attend appointments(particularly for those aged 15years or under)*

YesNoThey 16 years or older - (Not applicable)

Referral's full name

PrefixFirst NameMiddle NameLast Name

Pronouns

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number

Email

example@example.com

Do they Identify as (please select one or more)?

Referral's full name

PrefixFirst NameMiddle NameLast Name

Pronouns

Relationship

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number

Email

example@example.com

Do they Identify as (please select one or more)?

Referral's full name

PrefixFirst NameMiddle NameLast Name

Pronouns

Relationship

Organisation

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number

Fax number

Email

example@example.com

Concerns

Mind Body Innovation Centre is not a crisis support service. We are unable to provide adequet support for someone exerpeincing Active suicidle ideation.

Active suicidle ideation is difined as having a plan, access to means, intent, preparing for, rehursing and/or at imminant risk of self-inflicted death or serious injury.

If the person is at high or acute risk of suicide, please contact the Mental Health Line on 1800 011 511 or emergency services on 000 if urgent.

Please provide details

What service are you referring to?*

Therapy - Mental Health Treatment Plan(MHTP)Mind Body Launch ProgramWeight Management SupportTherapy - Eating Disorder Treatment Plan (EDP)Other (please specify below)

Please provide details

Please attach any extra relevant information and assessments e.g. Mental health care plans, Risk Assessment, A1, Discharge Summary

Please provide any other relevent information*

Please note: Once you sumit the referral you will be able to download a copy for your records.

Thank you for your referral,

ph: 02 4086 7141 | fx: 02 4989 6955
ad: Level 1, Suite 1 / 21 Annie St, Wickham NSW 2293
wb: mbicentre.com.au
em: hello@mbicentre.com.au

Mind Body Innovation Centre Referral Form

Consent to Referral

Person's Details

Next of Kin

Referrer Information

Presenting Concerns

Referral Information (please complete)