Patient Referral Form

Secure Referral to Place Psychology

🔒 Privacy & Security This form is secure and all patient information is handled in accordance with Australian privacy laws. By submitting this referral, you confirm that you have the patient's consent to share their information for the purpose of mental health treatment.

Select Practice Location

Please select a practice location

Referring Doctor Details

Please enter your name
Please enter practice name
Please enter a valid email address
Please enter a valid phone number

Patient Information

Please enter patient name
Please enter date of birth as DD/MM/YYYY
Please enter a valid phone number
Please enter a valid email address
Please enter a valid Medicare number
Please select position on card
Please enter expiry date as MM/YYYY

Referral Details

Please provide referral details
🔧 Admin Test Mode

Test the form connection without submitting real data:

Submitting your referral...

Referral Received!

Thank you for referring your patient to Place Psychology. We will contact them within 24-48 hours to arrange an appointment.

You will receive a confirmation email shortly.

What Happens Next:

✓

Within 2 Hours

  • Automated confirmation email sent to your practice
  • Patient added to our priority booking system
24h

Within 24 Hours

  • Patient contacted by phone (3 attempts)
  • Appointment scheduled
  • Confirmation sent to you
7d

Within 7 Days

  • Initial appointment completed
  • Comprehensive intake report sent
  • Treatment plan communicated
🎯 No Waitlists, No Delays

Unlike many services, we maintain capacity for new referrals. Your patient will be seen within days, not weeks.

Direct GP Support Line: 02 4210 5206
For urgent consultations or complex cases

Learn More About Our Practice