Referral/Admission form
SPECIALIST TREATEMENT AND REVOVERY MENTAL HEALTH SERVICES	

INPATIENT	
	
COURSES AND PROGRAMS	

Depression 
Anxiety Addictions
Aged Psychiatry	
	
Wellbeing Courses
Group Therapy Sessions
Recovery Programs	

T 03 6247 9960
F 03 6247 6439
E admissions@thehobartclinic.com.au
www.thehobartclinic.com.au	

REFERRAL DETAILS	
NAME 	<<Patient Demographics:Full Name>>	DOB	<<Patient Demographics:DOB>>	
ADDRESS 	<<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>	
EMAIL	<<Patient Demographics:E-mail>>	PHONE	 (h) <<Patient Demographics:Phone (Home)>>  (m) <<Patient Demographics:Phone (Mobile)>>	
PRIVATE HEALTH FUND 	<<Patient Demographics:Health Insurance>>	MEMBERSHIP NUMBER			
	
REASON FOR REFERRAL (please attach further documentation if required)	
<<Reason for referral>>	
	
SIGNIFICANT PAST HISTORY	
<<Clinical Details:History List>>		
	
CURRENT MEDICATIONS	
<<Clinical Details:Medication List>>	

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	<<Doctor:Name>>	
PROVIDER NO.	 <<Doctor:Provider Number>>	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