REFERRAL FOR MBS ITEM 291 BOOKED PSYCHIATRIC ASSESSMENT –NON -URGENT

Date: 

To: 		o	Dr Albert Matti  o Dr Titus Mohan   o Dr Rohan Dhillon  o Dr James Lally  
      		o	Dr Arun Gupta	o	Dr Tushar Singh o  Dr Sarath Attanayake   
		o  Dr Devon Marshman  Dr Tarun Bastiampillai

Re:	Name:		
	Address:	
	
	Telephone:	(Home)                      Mobile:	
	DOB:		
	Medicare No:		
________________________________________________________________________________________________________________________________
As we are a non-urgent MH service, level of risk will determine if your patient is appropriate for our service. If no level of risk is selected, this may cause a delay in scheduling an appointment

RISK: o Low		o Moderate			o	High
 
Reason for Referral:(Please give us as much relevant information as possible)

Past History:(please include: any relevant Family, Social or Forensic history)

	

Medications:

Employment:

Assessment suitability Criteria must complete this section)

Require assessment for 3rd party?	r No      	
Attention Deficit
Disorder?	r No	

Will you be responsible for continuing care of the patient?	r Yes       	Intellectual Disability?

ASD? 	r No
r No	
Is a one off assessment and  management plan appropriate   support for the care of your patient ?
	
r Yes	 Is your patient
 in a crisis situation?
	r No  

If Criteria is not met:  Consider referral to a private psychiatrist. Contact Mental Health Triage if in a crisis situation or risk is high, as well as for advice on referring to a Community Mental health team and if appropriate.

Additional Comments:

Patient agrees to this referral?	 o Yes          o No	

Patients Signature:		

Regards, 
Doctor:							(Please tick if Regular GP?) o
Provider Number: 
Practice
Address:												Postcode:
Telephone: 

Fax with copy of GP Mental Health Plan if possible (Item 2710 /2702) to: (08) 7425 8608 . Telephone: (08) 7425 8505