Psychological Treatment Service in Residential Aged Care Facilities (RACF) Referral Form

Clear Health Psychology is working collaboratively with the WA Primary Health Alliance (WAPHA) to deliver individual and group psychological treatment services onsite to residents in Residential Aged Care Facilities.

Patient Information

Please ensure the referral is made out from the GP and that all the below information is filled in. If any information is missed, we will be unable to book your patient in with a clinician until all the details are received.

Aged Care Home Staff can assist with filling details in on the referral and then have it signed by the GP.

Client First Name *

Client Last Name *

Date of Birth *

Is the client of Aboriginal or Torres Strait Islander decent? *

Facility Name & Phone Number *

Facility Email (Appointment Notifications) *

Room No *

Facility Address *

Street address *

City *

State *

Postcode *

Health Care Card *

Proficiency in spoken English *

GP Referral Details

GP Name *

Referrer Title *

Address for GP (associated with provider number) *

Street address *

City *

State *

Postcode *

Email address of GP *

Phone number of GP *

GP Provider Number *

This information needs to be completed and correct as we are required by WAPHA to have the GP endorse any referrals made by RN or NP. If we do not have these details, we will not be able to schedule in sessions.

Reason for Referral

Issue/Diagnosis *

Does the patient have a recent history of suicide attempt, or is at risk of harming themselves in the present? *

YesNo

Current Medications

MEDICATION ANTIPSYCHOTICS *

MEDICATION ANXIOLYTICS *

MEDICATION HYPNOTICS & ANIPSYCHOTICS (N05C) *

MEDICATION ANXIOLYTICS (NO5B) *

MEDICATION PSCHOSTIMULANTS & NOOTROPICS (N06B) *

MEDICATION ANTIDEPRESSANTS (N06A) *

I have disclosed this referral with and obtained the residents consent *

YesNo

Please advise us on agedcare@clearhealthpsychology.com if the referral has not been disclosed with the resident/no consent given

GP Signature *

Draw signature|Type signatureClear

Date of Referral *

Please press the submit button at the bottom of the form for the referral to be returned to the Aged Care Department for processing.

If you require any further information please call the Aged Care Team at Clear Health Psychology on 08 6378 4710 or email agedcare@clearhealthpsychology.com