Murrumbidgee Local Health District AccessLine Referral Form
Fax the completed form to: 1300 132 304 or Email to: AccessLine@medibank.com.au
(If you receive this fax by mistake, please re-fax to above number)
Client/patient details 
Surname:  <<Patient Demographics:Surname>>    Given Names: <<Patient Demographics:First Name>>	
     Sex: <<Patient Demographics:Gender>>   Date of birth: <<Patient Demographics:DOB>>	
Age: <<Patient Demographics:Age>>

Preferred phone number: <<Patient Demographics:Phone (Mobile)>>  <<Patient Demographics:Phone (Home)>>

Address:  	<<Patient Demographics:Full Address>>

Mental Health Diagnosis and/or substance use issue: <<Clinical Details:History List>>

Current Risk:

	Suicide:	 		Low  		Medium 		High 
	Self Harm: 		Low  		Medium 		High 
	Harm to others:		Low  		Medium 		High 

Relevant Medication: <<Clinical Details:Medication List>>
						
Current Concern: <<Current Concern>>

Requested Referral: (To be filled by health professionals only) 
Community Mental Health Team: 

Drug and Alcohol:: 

Other: 						Other, please specify:

Referrer details 
Name: <<Doctor:Name>>
	
Address:  <<Doctor:Address>>	
Preferred contact method:   Phone <<Doctor:Phone>>	Fax:  <<Doctor:Fax>>	 Email: <<Doctor:E-mail>>

Organisation:<<Practice/Location:Name>>

    Or please use stamp:

Acknowledgement:
I acknowledge that the client/patient named above has been provided with information about the AccessLine and has provided verbal informed consent to their information being sent to the AccessLine.
                   I acknowledge that the above request relates to a NON urgent matter.
Signature:						Date:

Confidential – Privacy Warning. The information contained in this fax message is intended for AccessLine staff only. If you are not the intended recipient you must not copy, distribute, take any action reliant on, or disclose any details of the information in this fax to any other person or organisation.