Referral Form
This form is designed for website eReferral, PDF referral, Medical Objects referral, or secure email referral. For electronic submissions, completion of referrer details and the declaration below constitutes authorisation by the referring practitioner.
1. Referrer Details
Referrer Full Name
*
First Name
Last Name
Provider Number
*
AHPRA Number (If Known)
Role
*
GP
Psychiatrist
Other
Practice Name
*
Practice Phone
*
Format: (00) 0000-0000.
Practice Email
*
Referrer Declaration
*
I confirm I am the referring practitioner, the patient has consented to this referral and sharing of relevant clinical information, and the information provided is accurate to the best of my knowledge.
2. Patient Details
Patient Full Name
*
First Name
Last Name
Date Of Birth
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Phone
*
Format: (00) 0000-0000.
Email
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medicare / DVA / NDIS Number (If Relevant)
Preferred Clinic Location
Margate
Caboolture Type
Either
Referral Urgency
Routine
Semi-urgent
Urgent
3. Clinical Summary
Primary Diagnosis / Reason For Referral
*
Brief Clinical Summary & Relevant Psychosocial Background
Current Medications, Doses, & Recent Medication Changes
*
Risk Concerns, Recent Hospital Admissions, Suicide/ Self-harm Concerns, or Relevant Safety Information
Current Treating Psychiatrist/ Psychologist/ Mental Health Team, If Known
4. TMS Clinical Screening
History of seizure, epilepsy, or unexplained loss of consciousness
Significant neurological history or brain injury
Medical implant, implanted device, metal in head/neck, cochlear implant or pacemaker
Pregnant or possibility of pregnancy
Significant alcohol or substance use concerns
Current suicidal ideation, recent self-harm, or acute risk concerns
History of bipolar disorder, mania, psychosis, or rapid mood elevation
Previous TMS or ECT treatment
Previous psychotherapy / counselling
Previous trial of at least two antidepressants
DVA funding
Private health fund / NDIS funding
5. Referral Authorisation & Privacy
I confirm the patient has consented to this referral and to the release of relevant clinical information to Connected Minds TMS for the purpose of triage, assessment, treatment planning, and communication with treating practitioners involved in their care.
By checking, I agree to share my form responses.
Electronic Signature / Typed Name
*
First Name
Last Name
Date Submitted / Auto-generated timestamp
Secure Submission ID / Internal Use
6. Submission Instructions
Please submit via secure website form, Medical Objects by searching "Connected Minds TMS", or secure email to admin@connectedmindstms.com. Our team will contact the patient directly to arrange assessment. Electronic submissions should retain date/time, referrer details, and submitted clinical information as an audit trail.
Submit
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