We have received your referral and require additional information. Please fill out this form with as much detail as possible so that we can triage your patient and book appointments for them with a suitable clinician

Patient Details

Patient's full name

Date of Birth

Who do you want to book in with?

Main Presenting Complaints / Symptoms - please tick all that apply

Mood Symptoms

SleepAppetiteEnergyChanges in moodMotivationReduced interest & enjoymentSocial withdrawalMeltdowns / explosive reactions

Developmental Concerns

Missed / delayed milestonesEye contactCommunication (verbal / non-verbal)Social interactionResponse to change"Black and white" thought patternRigid routinesStimming e.g. pacing, hand wringing, facial grimacing, etc.

Concentration Concerns

Concentration / attention / focusDisruptive behavioursMotivationDaydreamingPoor organisation Losing thingsMemory problems

Anxiety Symptoms

Panic attacksRuminations / excessive worryingObsessional symptoms - e.g. intrusive thoughts, compulsionsNightmares/ FlashbacksSocial anxiety

Eating Concerns

RestrictingBingeingFussy eaterCompensatory measures e.g. purging/vomiting, excessive exercise, laxative use etc

Risk to self/others

Self harmSuicidal ideationSuicide attemptsImpulsivity

Patient History

Family history

Anxiety DepressionASD / ADHDBipolar Affective DisorderDrug-induced psychosis / schizophrenia

Drug / Alcohol Use

THCVapingSmokingAlcohol

Current potential stressors

FamilyFriendsSchool / workMoneyPast/current trauma

Previous treatment

PediatricianHospital admissionsPsychological treatmentOther psychiatric treatment

Any other additional information regarding your referral that may assist in triage:

GP's Name

GP's Signature *

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