HNCPHN Telehealth Psychiatry — ACCHO Referral Form

HNCPHN Telehealth Psychiatry — ACCHO Referral Form

Complete the GP and patient details, eligibility declaration, IAR-DST scoring, and upload the referral letter and any supporting documents.
Eligibility
Please complete this section carefully. If the patient does not meet all criteria you will not be able to proceed. Internal intake will decline any referral where incorrect information is provided.
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 IAR-DST training
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 must reach the threshold of a Level of Care 3 or 4 to be eligible for this service. Please navigate them to an appropriate service, and feel free to reach out should you have any questions.
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
Referring GP Full Name

First NameMiddle NameLast Name
Provider Number
Practice/Service Name
Please select your ACCHO
Practice Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Direct Email
For psychiatrist correspondence to be sent
Practice Phone
Format: (00) 0000-0000.
Mobile Number
(optional)Format: 0000 000 000.
Why should I provide my personal mobile? — by providing your mobile you will be added to Dokotela's psychiatrist help forum, giving you 24-hour access to 70+ psychiatrists where you can ask any clinical questions, general or patient-specific, at any time (instant messaging platform).
GP Referral Letter

Please upload your standard GP referral letter. It should include current medications with name and dose, any relevant psychiatric or medical history, recent pathology or investigations if available, and the reason for referral. A Mental Health Treatment Plan is not required but should be noted if one exists. This does not need to be a formal document — but requires date, name (patients and yours), provider number & signature.
Cancelof

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.