General Psychiatry

GP Referral – General Psychiatric Assessment & Management Plan

Full name *

Date of birth *

Mobile *

Email *

Address

Medicare number (optional)

DVA number (optional)

Interpreter needed?

Interpreter language (if applicable)

Referrer name *

Provider number (optional)

Practice name

Phone / email for correspondence *

Referral date *

Urgency

Presenting symptoms / working diagnosis *

Key questions for the psychiatrist

Risk & safety

Suicidal ideation / self-harm history

Psychotic symptoms

Aggression / violence risk

Severe intoxication/withdrawal concerns

Telehealth & logistics

Patient has a private space + stable internet for telehealth

If risk: local crisis pathway identified

Declarations & consent

Patient consent confirmed * I confirm the patient has consented to this referral and the sharing of relevant health information for assessment and reporting back to the referrer.

Referrer declaration * I confirm the referral is dated and the information is accurate to the best of my knowledge.

Referrer name (as signature) *