3 Tier Youth Mental Health Program Youth Counselling Service Referral Form Clients Aged 12>25 Patient consent given for counselling Date of Referral: _______/ ______ / _______ Patient must have a GP Mental Health Treatment Plan GP Details (please use stamp if available) Patient Details Name: ………………………………………………………………………………. Name: ………………………………………………………….……………………………………… Address: …………………………………………………………………………… Address: ……………………………………………………………………………………………… Postcode: …………….. Postcode: ………………. Gender: Male Female Other GP signature ……………………………………………………………………. DOB: …… /..…/..… Provider Number ……………………………………………………………….. Medicare Number: …………………………………………………………………………… Preferred contact number: ………………………………………………………………… Preferred contact person to coordinate appointments: Name: ………………………………………………………………………………………………… Relationship to patient: …………………………………………………………………….. Contact number: ………………………………………………………………………………… Does patient have a HCC? Yes No MENTAL HEALTH TREATMENT PLAN ATTACHED (Tick box) Yes No ANY OTHER RELEVANT INFORMATION:
3 Tier Youth Mental Health Program Youth Counselling Service Referral Form Clients Aged 12>25 Date of Referral: _______/ ______ / _______ Patient consent given for counselling Patient must have a GP Mental Health Treatment Plan GP Details (please use stamp if available) Name: ………………………………………………………………………………. Address: …………………………………………………………………………… Postcode: …………….. GP signature ……………………………………………………………………. Provider Number ……………………………………………………………….. Patient Details Name: ………………………………………………………….……………………………………… Address: ……………………………………………………………………………………………… Postcode: ………………. Gender: Male Female Other DOB: …… /..…/..… Medicare Number: …………………………………………………………………………… Preferred contact number: ………………………………………………………………… Preferred contact person to coordinate appointments: Name: ………………………………………………………………………………………………… Relationship to patient: …………………………………………………………………….. Contact number: ………………………………………………………………………………… Does patient have a HCC? Yes No MENTAL HEALTH TREATMENT PLAN ATTACHED (Tick box) Yes No ANY OTHER RELEVANT INFORMATION: