PSYCHIATRY OUTPATIENT CLINIC REFERRAL FORM

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PSYCHIATRY OUTPATIENT CLINIC REFERRAL FORM Powered By Docstoc
					                                                                                   UR NUMBER

                                                                                   SURNAME

                                                                                   GIVEN NAME (S)
*FRC903100*


               PSYCHIATRY OUTPATIENT CLINIC
                                                                                   DATE OF BIRTH
               REFERRAL FORM
               (available from www.rch.org.au/mhs)                                 AFFIX PATIENT LABEL HERE




                                                       FAX: 9345 5034
              Please complete all sections of this form, preferably by typing. Your patient will receive a letter by mail
              with the details of their scheduled appointment and CC’d to you.
              For all enquiries please CONTACT (03) 9345 6180


              Preferred Contact Number: Mobile                                            Other
              Language spoken at home                                        Interpreter required       Yes   No


              CRITERIA FOR VACS PSYCHIATRY CLINIC INCLUDE:
              1. RCH patients aged 0-18 years with co-morbid mental health problems who may not meet the criteria
                 for entry to the specialist IMHP CAMHS clinics
              2. These mental health problems are causing significant distress or functional impairment to the child in
                 their family or school or other environment
              3. These are clients who are preferentially seen at RCH because they have ongoing need for care at the
                 hospital
              4. Clients are referred by RCH paediatricians



              CLINICAL DETAILS – including reason for referral / diagnosis




              Relevant Past History            Other




              1. Please include a list of current medications, any relevant pathology and imaging results with this
                 referral. This information will assist us to appropriately triage your patient.
              2. In addition to the above information you may attach a letter as well.
              Referral Duration             3 months             12 months          Indefinite   Other:
              (Type ‘X’ in the relevant box)


              REFERRING DOCTOR DETAILS
              Surname                                          Given Name
              RCH Department                            Phone No.                                  Fax No.

              Doctor’s signatures                                              Date
              Preferred Contact Type                                              E-mail:
              (Type ‘X’ in the relevant box)           Phone         Fax




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