Please send referrals to:
HelloDoc Telepsychiatry
Healthlink EDI: hellodoc
OR
referrals@hellodoc.com.au
OR
03 9001 0712	

FROM:

Name:	<<Doctor:Name>>	
Practice Name:	<<Practice/Location:Name>>	
Address:	<<Doctor:Address>> <<Doctor:City>> <<Doctor:Postcode>> <<Doctor:State>>	
Phone:	<<Doctor:Phone>>	
Fax:	<<Doctor:Fax>>	
Email:	<<Doctor:E-mail>>	
Provider #.	<<Doctor:Provider Number>>	
Referral date:	<<Miscellaneous:Date (short)>>	

PATIENT DETAILS:

Name:	<<Patient Demographics:Full Name>>	
DOB:	<<Patient Demographics:DOB>>	
Address:	<<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:State>>  <<Patient Demographics:Postcode>>	
Phone:	<<Patient Demographics:Phone (Home)>>  (m) <<Patient Demographics:Phone (Mobile)>>	
Next of Kin Contact # and Name	 <<Patient Demographics:Next of Kin Phone>>  <<Patient Demographics:Next of Kin>>	
Email:	<<Patient Demographics:E-mail>>	
Medicare Card /DVA No	<<Patient Demographics:Medicare Number>>  <<Patient Demographics:Medicare Expiry Date>>	

REFERRER DETAILS:

Referrer is a  (select one)
				
X	  GP		  Other____________________________	

Shared care model (tick if applicable)
		
	  Appointment to take place at GPs medical practice	

Reason for referral  (select one)
				
	  Psychiatric Assessment under 291		   Private patient/ non-medicare card holder (fees apply)	

Has the patient been reviewed by any private Psychiatrist in the last 12 months?
				
	  Yes		  No	

     referrals@hellodoc.com.au	    1300 959  942   	    www.hellodoc.com.au	

	Please send referrals to:
HelloDoc Telepsychiatry
Healthlink EDI: hellodoc
OR
referrals@hellodoc.com.au
OR
03 9001 0712	

Reason for referral:

	
Past psychiatric history (including hospital admissions:

	
Medications: <<Clinical Details:Medication List>>	
Risk concerns (eg. suicidal ideation, past suicidal attempts, self-harm, forensic / police
involvement, violence):

	

     referrals@hellodoc.com.au	    1300 959  942   	    www.hellodoc.com.au