URGENT APPOINTMENT REQUEST
The below information is necessarily in helping us to triage your request
Name of person requiring appointment
First Name
Last Name
Date Of Birth
-
Day
-
Month
Year
Date
Phone Number
Format: (000) 000-0000.
Email address
example@example.com
Preferred method of contact
Please Select
Phone call
Text message
Email
Contact support person instead
Nominated support person to contact and their best contact details
Do you have a current valid referral from your GP specialist?
Please Select
Yes
No
I am not sure
I will be obtaining one BEFORE the appointment with Dr Kaur
Current concerns
Current medication list
Known Diagnosis
Mood Disorder
ADHD
Autism Spectrum Disorder
Anxiety Disorder
Eating disorder
Learning disorder
Psychotic disorder
Adjustment Disorder/ Acute Stress Reaction/ PTSD
Personality vulnerabilities/ disorder
Illicit drug and/ or alcohol misuse
Other
Previous risk concerns
Deliberate self harm
Suicide attempts
Other
Current risk concerns
Deliberate self harm
Other self-injury
Suicide attempt
Other
Current protective factors
Social support/ family/ friends etc
Demonstrates help-seeking behaviour
No current/ active suicidal ideation or plan
Is in a contained/ risk-mitigating environment
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