Elyséa HEALTH Referral Form

Referrer Details

Referrer is a: *

General Practitioner

Nurse Practitioner

Other

Name *

Practice Name *

Practice Email (Preferred way of communication) *

Address *

Post Code

Phone

Provider No

Referral Date

Patient Details

First Name *

Surname *

Email *

Address *

Date of Birth

Post Code

Phone

Medicare Card

Next of Kin, Contact No, and Name

Reason For Referral

Select one:

Psychiatric assessment under 291

Psychiatrist Appointment for Ongoing Care (if accepted).

Private patient/ non-Medicare card holder

Review appointment for existing patient (MBS 293 or other relevant item number)

Psychologist Appointment

Details for Referral

Past psychiatric history (including hospital admissions) *

Medications

Risk concerns (eg, suicidal ideation, past suicidal attempts, self-harm, forensic / police involvement, violence)

Supporting Documents

Maximum file size: 20 MB

Please advise your patients to call us if they have not heard from us within 5 business days of sending the referral.

Ready to Start?

Begin your path to greater resilience and wellbeing with compassionate, expert care from our dedicated Elyséa HEALTH team. Our clinicians and support staff are here to guide and empower you every step of the way.

Elyséa HEALTH Referral Form

Referrer Details

Patient Details

Reason For Referral

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