Referral Form

PARTICIPANT CONTACT INFORMATION

First Name *

Last Name *

Referral Type *

Residential Address *

Contact Number *

Email *

Date of Birth *

Age

Gender

Medicare Number

Ref No.

Expiry

GUARDIAN CONTACT DETAILS (If applicable)

Full Name

Contact Number

Relationship

REFERRAL DETAILS (N/A if self referral)

Referral Date

Contact No.

Organisation

Referrer Name

Position

Address

Other Information *

PRE-EXISITING DIAGNOSIS/MEDICAL HISTORY

ARE YOU TAKING ANY MEDICATIONS THAT WOULD BE BENEFICIAL FOR US TO KNOW?

Appointment Preference

Face to faceTelehealth

RISK INFORMATION

Previous preentations to Emergency Department or Hospital? *

Previous hospitalisation for mental health concerns? *

Previously received any type of mental health care? *

ADDITIONAL PARTICIPANT INFORMATION (Minimum Data Set)

Relationship Status *

Indigenous Status *

Country of Birth *

Main Language Spoken at Home *

LGBTIQ+ *

Risk of Homelessness *

Labour Force Status *

Employment participation *

Primary Source of Income *

Holder of a Health care Card *

Are ther any Current or Pending Legal Matters e.g, DV, Family Law, Child Safety *

Participant with a National Disability Insurance Scheme (NDIS) plan? *

If yes, please provide Participant Number and details for Plan Manager if applicable (Type N/A if not applicable) *

SUPPORT BEING REQUESTED

Low Intensity / Psychological Therapy (LIPT Funding – Banana/North Burnett Region only)Care Coordination for Severe and Complex Mental Health (Professional Referral)NDIS ServicesWorkcoverMedicare (Selected regions)Private Fee Paying Services

CONSENT TO REFERRAL

The Participant has been informed about and consented to the information on this referral being shared with the Primary Health Network for consideration of eligibility requirements for funded services outlined above. Non-consent will mean acceptance for private fee paying services. *

Participant ConsentGuardian ConsentNo

Please Note: We will endeavour to respond to Referrals within 3 working days, but this may be delayed with demand for services.

If you have not received confirmation of receipt of this referral, please call us on 07 4992 1040.

Please Note:

CQRH is not an acute mental health/crisis service. If you have any immediate concerns regarding the safety/wellbeing of yourself or someone else, please call: 1300 MH CALL (1300 642255), Lifeline 13 11 14; or Kids Helpline 1800 55 1800. In an emergency, contact 000 immediately.