Mental Health Referral

Referral For





 (* Your referral will be assigned to the most appropriate specialty.)

 

Details of Referring
Name:
Address:
Contact Numbers:
Email address:

Patient Details

Name:
Address:
DOB:
Contact Number:
Email address:
Is the patient privately insured:
If YES which Company:

Referral Details

Reason for referral:
Main presenting problems:
Past psychiatric history and previous psychological treatment
Previous medication:
Previous psychotherapy & counseling:
Past medical history:
Current Medications:
Data Protection: We respect your privacy. All clients details provided are kept securely and are only used for referral and treatment purposes. We do not share any information with third parties without seeking consent.

Submit Referral

We deal with all consultants and all specialties – we aim to place your patient with an appropriate specialist within 7 working days. Thank you for your referral.

Visit our diagnostic test forms library

Approved by*:

approved by logosapproved by logos

*Some exceptions apply. Contact your Health Insurance Provider for details.

H3 Insurance