Thank you for considering us when referring your patient to see a specialist.

Please note that we only accept non-urgent referrals. Our reception is open 8:30am-5pm Monday to Friday to answer any enquiries.

Referrals

Please fill in the below Referral form, once completed click submit and this will confidentially be received by our receptionists. Alternately there is a downloadable PDF referral that you can fill in and fax to 9264 8282 (new no), or email to reception@blsc.net.au

Please note that we do not take on ADD/ADHD referrals, also any insurance covered referrals must be prior approved.

ABOUT THE CLIENT:

Surname:

First / Given Names:

Gender:

MaleFemale

Date of Birth:

Medicare No:

Address (Current):

Next of Kin and contact details:

Medical History:

Current Medication:

Alergies:

CLINICAL DETAILS:

DepressionAnxietyOCDPTSDPsychosisSomatics/sManiaDaily mood fluctuationsImpulsivitySocially withdrawnInterpersonal IssuesIssues with AlcoholIssues with StimulantsIssues with Benzo’sIssues with OpioidsIssues with OtherADHD / Eating Disorder PLEASE REFER ELSEWHERE

1. Please elaborate:

2. Second Opinion:

3. Ongoing management (any specific issues):

4. Risk issues (acutely suicidal clients need referral to MHERL/ED):

5. History of aggressive or assaultive behaviour:

6. Forensic/legal matters known:

REFERRER DETAILS:

Referrer's Name:

Provider No:

Date of Referral:

Contact Details: