GIVEN NAME (S)
PSYCHIATRY OUTPATIENT CLINIC
DATE OF BIRTH
(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
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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