Eton Place GP Referral Form

Please provide as much information as possible to facilitate the booking process for your patient and their caregivers.

If you are referring a patient below 18 years old, we highly recommend parents/caregivers are referred as part of the child’s comprehensive initial diagnostic evaluation and ongoing treatment process.

We are subscribed to Medical-Objects. Please send your referral via Medical-Objects whenever possible.

(If you are a patient/carer, please do not complete this form by yourself. We require your GP to complete this for the referral to be valid)

Referral Details

Referral Date *

Is the patient under 18 years old *

YesNo

Are you referring the parent/caregiver as well? *

YesNo

Parent/Caregiver Details

Surname *

Given Name/s *

Date of Birth *

Relationship to Patient

Residential Address

Street address

City

State

Postcode

Patient Details

Surname *

Given Name/s *

Gender

Date of Birth *

Mobile Phone *

Email *

Address

Street address

City

State

Postcode

Please leave blank if same as parent/caregiver address

Who do you want to book with?

Psychiatrist/Psychiatry Registrar

Psychologist

Occupational Therapist

Accredited Mental Health Social Worker

Presenting Complaint and Treatment Goals

Reason for Referral

Development

Speech/ languageIntellectual performancePeer relationshipsDevelopmental delay

Function

SchoolHomeWorkFriends

Eating Concerns

Restricting/ BingeingCompensating (purging, exercising, laxatives)

Risks

SelfOther

Additional Information

Number of Sessions (MHCP) *

6 Invididual4 Individual

Are you referring for psychological assessments?

Cognitive (psychometric)ASDADHDLearning difficulties

Please note assessments may not be covered by Medicare rebates.

General Practitioner Details

In order to receive a Medicare rebate, we require a valid GP Referral for both the patient and the parent/carer of the patient.

Practitioner Name *

Provider Number *

Practice Name *

Practice Address

Street address

City

State

Postcode

Phone Number

Fax Number

Email Address

Signature *

Clear