Self-Referral Form

For mental health advice and guidance

Or call 1800 595 212 between 8am and 6pm Mon to Fri (excluding public holidays)

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

Are you completing this request for yourself or on behalf of someone else? *

For myselfOn behalf of someone else

What is your relationship to the person? *

Is the person aware and consenting of you making this referral? *

YesNo

First name *

Last name *

Date of birth *

Gender *

Aboriginal and/or Torres Strait Islander Origin *

Mobile/Phone Number *

Email Address

Street addressStreet address line 2

City *

State *

Postcode *

Country

Consent to be contacted via *

PhoneSMSVoicemailEmail

How can Medicare Mental Health help you?

Tick all that apply below:

Managing my mental healthSocial skills and connection, including family connectionsDay to day living skills including help accessing financial support and budgetingFinding and maintaining a homeMaintaining physical wellbeing, including exercise and linking with health professionalsBuilding broader life skills including confidence and resilienceParenting supportSupport with Suicide PreventionSupport for grief and loss

Or tell us in more detail:

Are you having suicidal thoughts? *

YesNo

MEDICARE MENTAL HEALTH IS NOT A CRISIS SERVICE. IF ANY PERSON IS AT IMMEDIATE RISK PLEASE CALL 000

For general enquiries to the Western Queensland Medicare Mental Health team, please call 1800 595 212 or email mmh@rhealth.com.au
Website www.medicarementalhealth.gov.au

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