HNCPHN Telehealth Psychiatry — Commissioned Service Referral Form

HNCPHN Telehealth Psychiatry — Commissioned Service Referral Form

Complete this form to refer a consumer to the HNCPHN Telehealth Psychiatry service. Internal intake will assess and decline any referral where incorrect information has been entered.
Eligibility
Complete this form if you are from a Healthy North Commissioned Service to refer a consumer to the telepsychiatry service. Telehealth Psychiatry service. Please ensure the consumer meets all eligibility criteria and that the information provided is accurate. Eligibility will be confirmed during the Dokotela intake process. Referrals for patients who do not meet the eligibility requirements may be declined, potentially delaying access to care.
Eligibility Declaration

IAR-DST Assessment
Before completing the fields below, please open and complete the IAR-DST using the official tool. Click here to open the IAR-DST tool: iar-dst.online — complete all 8 domains, then return here to enter your scores.
I confirm I have completed a comprehensive mental health assessment and derived a level of care using the IAR-DST— must be ticked before proceeding
How would you like to provide the IAR-DST
Upload completed IAR-DST

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Symptoms and Distress
Risk of Harm
Functioning
Co-existing Conditions
Service Use History
Social and Environmental Stressors
Family and Other Supports
Engagement and Motivation
Total Score
Level of Care
This patient does not meet the eligibility threshold for this service. Level 3 or Level 4 is required.
This patient requires an immediate and more intensive level of care than this service can provide. Please refer urgently to an acute mental health service or emergency department. Do not wait for this referral to be processed.

Referrer Details
Referrer Full Name

First NameMiddle NameLast Name
Your Role or Position
Service Name
Service Phone
Please enter a valid phone number.Format: (00) 0000-0000.
Contact Email
example@example.com
GP Referral Letter — how will this be provided
Upload GP Referral Letter

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All patients who access this service MUST have a treating primary carer (General Practitioner). The GP is expected to manage clinical treatment between appointments with the psychiatrist, and the psychiatrist addresses their treatment plan to the GP.
Patient's Usual GP Details
Would your service like to host appointments for this patient
Will a worker from your service attend appointments with the patient

REFERRAL CANNOT PROCEED

This referral cannot proceed. The Level of Care selected does not meet the eligibility threshold for this pathway (Level 3 or 4). Please refer to a more appropriate service.