PSYCHIATRIST / PSYCHOLOGIST / ACT THERAPIST REFERRAL
PATIENT DETAILS	
Name: 	Date of Birth: 	Gender	
Address: 	
Home Phone:	Mobile: 	
Email:	
☐     Mental Health Care Plan	☐  Concession Card Holder	
☐    WorkCover	☐  Private Health Insurance	

REASON FOR REFERRAL	
☐	Adjustment Disorder	☐	Bipolar Disorder	☐	Grief and Loss	
☐	Anxiety, OCD etc 	☐	Relationship / Marital	☐	Pain / medication issues	
☐	Depression	☐	Asperger’s / Autism Spectrum	☐	Eating Disorder	
☐	Adolescence Issues	☐	PTSD / Acute Stress	☐	Alcohol / substance abuse	
☐	Other:	
Clinical Notes:

	

PREFERRED CLINICIAN	
☐   Next available	 ☐ Day Only	☐  Evening Appt Only	
PSYCHIATRISTS	
☐  	Dr Robert Purssey	☐	Dr Nga Tran	
PSYCHOLOGISTS	
☐	Roz Hurst	☐	Georgia Watkins-Allen	☐	Rhys Burridge	
☐	Bernadette Devenish	☐	Renae Jarrett	☐	Jenny Laing	
☐	Nikita Kotlarov	☐		☐		
Accredited Mental Health Occupational Therapist  ☐ Robbie Ellett  ☐ Claire Welsh (home visit)	

REFERRING DOCTOR DETAILS (Including Provider No.)	
Please type in details: 

	
Date: 	

Client will be contacted by Brisbane ACT Centre staff with appointment options / details