Initial Referral and Mental Health Care Plan v2

General Practice Initial Referral and Mental Health Care Plan
Please review the eligibility criteria on our website to ensure the suitability of this service.

Gidget Foundation Australia is a non-multidisciplinary organisation. Our clinicians offer support for those experiencing, or at risk of developing perinatal depression, anxiety, or perinatal related stress disorders. Support is also provided to those people and their partners, who have experienced birth trauma or pregnancy related loss.

We are dedicated to providing care that is safe, effective and meaningful within the parameters of the resources available to us. As a result, we are unable to accept referrals of people in crisis. The eligibility questions below will assist your patient in accessing the most suitable care for their current situation.
My patient is currently experiencing, and does not have additional specialised support in place for (please tick any relevant boxes)*

Current or enduring psychotic illnessCurrent serious suicidal, homicidal or infanticidal ideationCurrent child protection and/or family violence or issues requiring Department of Community and Justice involvementCurrent serious substance abuse that requires medical interventionIs NOT experiencing any of the above
Unfortunately, your patient falls outside our eligibility criteria. In their best interest, please refer your patient to an alternative service.
Patient Name*

First NameLast Name
Medicare details
Number Number* Expiry Date e.g. 05/2026* Ref. Ref. Number*
Date of Birth*

DayMonthYear
Date
Gender*
Mobile Number*
In order for our system to correctly send a notification to the patient, please leave off the 0 from the beginning of the mobile number and start after the first 3 numbers listed above.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
In case of emergency
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*
Please enter a valid phone number.
I, Dr Name* refer client blank*, to Gidget Foundation Australia for 6 sessions of perinatal psychological services under the Better Access Mental Health Care Scheme.
I can confirm that my patient is being referred within the perinatal period of conception - first 12 months of parenthood.
Please choose whether the patient is in the antenatal or postnatal period*
EDD:

DayMonthYear
Date
Antenatal Period - Please select the specific reason for your referral (further details can be added below.)*

Anxiety/depression (PNDA)MiscarriageTerminationParent or baby diagnosed with medical complicationsAssisted conception complicationsPrevious pregnancy birth traumaPrevious antenatal lossPrevious postnatal lossPNDA with previous pregnancies
Baby's DOB:*

DayMonthYear
Date
Postnatal Period - Please select the specific reason for your referral (further details can be added below*

Anxiety/depression (PNDA)Parent or baby diagnosed with medical complicationsBirth traumaPremature babyStillbirth
To help us deliver the best care possible, please provide all relevant diagnosis or reason for referral.
The Gidget Foundation's team of specialist perinatal clinicians work with those experiencing perinatal depression and anxiety. Our Eligibility Criteria is in place to ensure patients are directed to the most suitable service to receive timely and appropriate care.
Signature*

Clear

Please enter your details*

	Detail
Your Name:
Provider Number:
GP Surgery Name:
GP Surgery Address:
GP Surgery Phone Number:
GP Surgery Fax Number:

	Detail
Appearance
Orientation
Cognition
Memory
Mood
Affect
Speech
Thought content
Self-esteem
Judgement
Formal thought disorder

General Practice Initial Referral and Mental Health Care Plan

Patient Assessment

Completing the Plan

Record of Consent