Referral Form for Professionals

Referral Form for Professionals
Please note that Mindgives is not an acute mental health service or crisis service. If you have concerns for a person's immediate safety, please contact:

* For urgent medical assistance please call: 000

* Psychiatric Triage Service (Monash catchment): 1300 369 012

* Peninsula Triage (Peninsula catchment): 1300 792 977
Client Details:
Client Full Name:*

First NameLast Name
Date of Birth:*

DayMonthYear
Date
Gender:
Email:
example@example.com
Phone Number:*
Please enter a valid phone number.
Emergency Contact Name:*
Emergency Contact Number:*
Please enter a valid phone number.
Support Person/ Guardian Name:
Support Person/ Guardian Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Method:*

Phone callEmailText before callContact a support person/ guardian
Medicare Information if know:
Number:Medicare #
Individual Reference Number:Ref #
Expiry:Date
Referrer Information:
Professional's Name:*

First NameLast Name
Role:*
Organisation:*
Facility:
Email:*
example@example.com
Contact Number:*
Please enter a valid phone number.
Best method to get in touch:

EmailMobile
Does the client have a Mental Health Treatment / Care Plan?*

YesNoNot Sure
If there is risk, has a safety plan been completed? If so, please provide details:
Please provide us with any other relevant background information:
Are there any other support services involved (e.g. NDIS, TAC, Workcover)? If yes, please provide details:
Please attach any additional relevant documents here:

Cancelof
If referring from a Tertiary Mental Health service (e.g. Monash Health), please include a Discharge Summary or full Formulation document. Thank you.
Collection and Use of Personal Information:
I have discussed the proposed referral with the young person, parent or guardian, and I am satisfied that they understand that their information will be collected and stored by Mindgives in order to provide care.*

I agree
Should be Empty:

Referral Form for Professionals

Client Details:

Referrer Information:

Collection and Use of Personal Information: