• HNCPHN Telehealth Psychiatry — Commissioned Service Referral Form

    Complete this form to refer a patient to the HNCPHN Telehealth Psychiatry service. Internal intake will assess and decline any referral where incorrect information has been entered.

  • 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.

  • How would you like to provide the IAR-DST*
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  • 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

  • Format: (00) 0000-0000.
  • GP Referral Letter — how will this be provided*
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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. 

     

  • 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.

  • Patient Details and Referral Information

  • Date of birth*
     - -
  • Format: 0000 000 000.
  • Does this patient hold a Medicare card*

  • Noted — This will be shared with the internal intake team, and will not limit the patient from accessing the service.

  • Interpreter required?*
  • Recent hospital admission?*
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  • Is this referral for the purpose of ADHD or ASD? (Neurodevelopmental)*
  • Neurodevelopmental Waitlist*
  • Should be Empty: