Mental Health Referral Form

To refer a patient with a Mental Health Treatment Plan to Sureway Health Support

Patient Details

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Street Address *

Town/City *

State *

Postcode *

Medicare Details

Name as written on Medicare Card *

Medicare Card Number *

Medicare Card Reference Number *

Medicare Card Expiry Date *

Plan Details

Mental Health Plan Date *

Planned GP review date *

Please provide a copy of the Mental Health Plan *

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Each referral to Sureway Health Support must be accompanied by a Sureway Health Support Privacy Form.

The below link can be pasted into an email or SMS and sent to the patient for completion.

Privacy Form: https://sureway-ndis.snapforms.com.au/form/sw-health-support---privacy-form

Referrer Details

Are you completing this form on behalf of the patient? *

Yes - I am the referring practitioner / GPNo - I am the patient

First Name *

Last Name *

Provider Number *

Practice Name *

Practice Address *

Email Address *

Phone Number *

Patient Representative Details

Does the patient have an authorised representative / advocate? *

YesNo

First Name *

Last Name *

Relationship to the patient *

Email *

Phone Number *

If the patient has authorised a representative to act on their behalf and/or attend Sureway Health Support appointments with them, a Sureway Health Support Advocacy Form must also be completed.

The below link can be pasted into an email or SMS and sent to the patient for completion.

Advocacy Form: https://sureway-ndis.snapforms.com.au/form/sw-health-support---advocacy-form

Type of Referral

If other, please explain further *

Predicted number of Sessions *

Type of appointment *

Any additional, relevant information

How did you hear about Sureway Health Support? *

Authorisation

By reviewing the below, the you confirm that:

This referral has been discussed with the patient and they have agreed to fully participate in counselling and associated Sureway Health Support activities. *

The patient agrees to be contacted by Sureway Health Support. *

The patient is aware that they must provide at least 24 hours' notice if they are unable to attend or participate in an appointment with Sureway Health Support. *

The patient has completed the appropriate Sureway Health Support Privacy and Advocacy Forms. *

The patient's Mental Health Plan has been provided to Sureway Health Support. *

The patient or representative (including the referrer) will contact Sureway Health Support if anything changes with this referral. *

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