Western Queensland

Medicare Mental Health

(Formerly Head to Health)

Mental Health Navigation

Referral Form

Or call 1800 595 212 between 8:30am and 5:00pm Mon to Fri

If you are outside of Western Queensland, please call 1800 595 212 instead of using this form.

Referrer details

Referral origin *

Referral date *

Referrer name *First name and last name

Referrer profession *

Organisation *

Other organisation *

Street address *Street address line 2

City *

State *

Postcode *

Country

Referrer email *

Referrer phone *

GP details

Recording these details is optional, if the client is happy for their GP details to be provided.

Are you this persons regular GP? *

YesNo

GP name

GP clinic

GP phone number

Does client have a MHTP? *

YesNoUnknown

If you are unsure, please select 'Unknown'

Client details

First name *

Last name *

Date of birth *If you are unsure, enter an estimate.

Gender *

PronounEnter the client's preferred pronouns

Aboriginal and/or Torres Strait Islander Origin *

Country of birth *

Main language spoken at home *

Other language *

Mobile *

Phone

Email Address

Street addressStreet address line 2

City *

State *

Postcode *

Country

Clinical information

Reason for referral *

Risk assessment

Current suicidal thoughts? *

YesNo

Current suicidal plans? *

YesNo

Current suicidal intent? *

YesNo

Current self-harm behaviours? *

YesNo

Additional details (Risk assessment)

Supporting documents/files

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For general enquiries to the Medicare Mental Health team, please email mmh@rhealth.com.au or call 1800 595 212.