GP Referral Form
Date:                                                                                  Health fund details: 
Name of Patient: 
Date of birth: 
Name of referring GP: 				      Provider number:
Address of Practice: 
Phone number:                                                                  Email address: 

1 	Type of referral:  
 Inpatient admission - Fax 9889 8696  
 291 assessment – Fax 9834 3666 
 Consultancy and ongoing care – Fax 9834 3666
 Day Program - Fax 9805 7395

2	Diagnosis
Please complete

3	Current presentation
Please complete

4	Drug & Alcohol history
Please complete

5	Past history
Please complete

6	Forensic history
Please complete

7	Current medications
Please complete

8	Medical conditions
Please complete

9	WorkCover/TAC applicable
Please complete