Referral/Admission form
SPECIALIST TREATEMENT AND REVOVERY MENTAL HEALTH SERVICES				
T 03 6247 9960
F 03 6247 6439
E admissions@thehobartclinic.com.au
www.thehobartclinic.com.au	
	INPATIENT		COURSES AND PROGRAMS		
	Depression 
Anxiety Addictions
Aged Psychiatry		Wellbeing Courses
Group Therapy Sessions
Recovery Programs		

REFERRAL DETAILS	
NAME 	<PtFullName>	DOB	<PtDoB>	
ADDRESS 	<PtStreet>, <PtCity>, <PtPostcode>  	
EMAIL	<PtEmail>	PHONE	 (h) <PtPhoneH>  (m) <PtPhoneMob>	
PRIVATE HEALTH FUND 	<PtInsFund>	MEMBERSHIP NUMBER	<PtInsNo>		
	
REASON FOR REFERRAL (please attach further documentation if required)	
<Reason for referral>	
	
SIGNIFICANT PAST HISTORY	
<SelectedPMH>		
	
CURRENT MEDICATIONS	
<SelectedRx>	

RISK ASSESSMENT	
	LOW	MODERATE	HIGH	EXTREME	IF PRESENT PLEASE ELABORATE	
Suicidality/Homicidality
Thoughts/Plan/Intention						
Deliberate Self Harm						
Aggression - Physical &/or verbal (including threats)						
Drug & Alcohol abuse						
Cognitive impairment						
Medical conditions						
Other						

REFERRING DOCTOR/ CLINICIAN	
NAME	<DrName>	
PROVIDER NO.	 <DrProviderNo>	SIGNATURE	

OFFICE USE ONLY
HEALTH FUND CHECK RESULT		EASTERN SHORE
31 Chipmans Road
Rokeby TAS 7019	
		CITY
Level 8/39 Murray Street
Hobart TAS 7000