Online Psychiatrist Referral

Referral for Psychiatrist: Assessment / Opinion & Management

Referral for Psychiatrist: Transcranial Magnetic Stimulation

ℹ️ Clicking submit will send referral to Bluebell Health & your patient if you have included their email. Your patient will be contacted by us within 3 business days. If your patient is unsure about starting treatment and wants more information, please note that and we will walk them through their options.

If you prefer a printable PDF you may download it here

ℹ️ Please select from one of the below options to bring up the appropriate online referral.

If you prefer a printable PDF you may download it here

Is this referral for a Psychiatrist assessment or TMS for depression? *

PsychiatristTMS

A TMS referral includes a Psychiatrist safety assessment & reviews

referral ref

ReferralSource

Patient Information

Patient First Name *

Patient Last Name *

Patient DOB *

Patient State *

Patient Email

Email Confirmation *

Email referral confirmation to my patientDO NOT email referral confirmation to my patient

Patient Contact Number *

Contact Number Type *

MobileHome

Do not send SMS confirmation to my patient

SMSvalidation

emailvalidation

Preferred Location(s)

NSW - Edgecliff (203-233 New South Head Road, Edgecliff NSW 2027)NSW - Fairfield (Fairfield City Central, L2, 54 Smart Street, Fairfield NSW 2165)NSW - Northmead (153 Windsor Road, Northmead NSW 2152)NSW - Sydney CBD (205/65 York Street, Sydney, NSW 2000)VIC - Melbourne (506/1 Queens Road, Melbourne VIC 3004)VIC - Officer (112-116/445 Princes Highway, Officer VIC 3809)QLD - Greenslopes (Greenslopes Private Hospital, 101a Newdegate St, Greenslopes, QLD, 4120)TELEHEALTH

Please choose preferred location/s (if any, or you may leave this blank)

Clinical history

Is the patient currently admitted to an inpatient facility? *

Yes, currently admittedYes, anticipated discharge within the next fortnightNo, planned admission within the next fortnightNo

Inpatient Status

Patient History *

Number of current/prior antidepressant trials *

Medication History

Other comments

Referrer details

Referrer First Name *

Referrer Last Name *

Referrer Provider Number *

Practice Name *

Practice Contact Number *

Practice Fax Number

Practice Email Address *

Street Address *

Practice Suburb *

Practice Post Code *

Practice State *

I confirm that my patient has consented to be contacted by Bluebell Health to discuss treatment and/or book in for their assessment
*

Referrer Signature *

Draw signature|Type signatureClear

Date *

This referral is valid for 12 months from the date of referral for my patient to complete a course of TMS

Our Locations

State	Suburb	Full Address
NSW	Sydney CBD	Suite 205, 65 York Street, Sydney NSW 2000
NSW	Northmead	153 Windsor Road, Northmead NSW 2152
NSW	Fairfield	Top Floor, Fairfield City Central, 54 Smart Street, Fairfield NSW 2165
NSW	Edgecliff	Suite 107, Level 1, Edgecliff Centre, 203–233 New South Head Rd, Edgecliff NSW 2027
QLD	Greenslopes	Greenslopes Private Hospital, 101a Newdegate Street, Greenslopes QLD 4120
VIC	Melbourne	Suite 506, 1 Queens Road, Melbourne VIC 3004
VIC	Officer	Units 112–116, 445 Princes Highway, Officer VIC 3809

referral sync

==== Initial {{referral type}} Referral Info ====

MEDICAL HISTORY

• Diagnoses: {{depression diagnosis}}, {{comorbidities}}

FUNDING INFORMATION

• Funding Type: {{patient funding source}}

REFERRAL INFO

• Initial Referral Date: {{date}}
• Referrer: {{referrer first name}} {{referrer last name}}
• Referrer State: {{practice state}}

SYSTEM AUTOMATION

• New Ref. Automation: {{referral ref}}
• SMS: {{smsvalidation}}
• Email: {{emailvalidation}}
• Inpatient Status: {{inpatient status}}

OTHER NOTES