MindSpot GP is a national provider of free online and telephone-based assessment and treatment for adults experiencing symptoms of depression, anxiety, and coping with chronic health conditions.

How to refer:
1.  Complete this form
2.  Fax the completed form to 02 9475 0249.

Who is eligible for MindSpot GP services?
•	Symptoms of mild to moderate anxiety, depression, or substance misuse that would benefit from a short term-intervention.
•	18 years and over (16 years and over in WA if referral is made by a GP in the Perth metro or Kimberley area, or by an Integrated Primary Mental Health Care provider).
•	If you are a GP referring from Country WA, please refer through your local IPMHC provider.

Referrer Details (Required)
Title	<<Referrer Title>>	
Full Name	<<Doctor:Name>>	
Profession	<<Profession>>	
Practice/Organisation type	<<Practice/Organisation type>>	
Practice/Organisation name	<<Practice/Location:Name>>	
Practice/organisation address	<<Doctor:Full Address>>	
Postcode	<<Doctor:Postcode>>	
State	<<Referrer state>>	
Phone	<<Doctor:Phone>>	
Email address	<<Doctor:E-mail>>	
Fax number	<<Doctor:Fax>>	

MindSpot GP HP Referral Form | July 2022 				    Page 1

Patient Details (Required)
First Name	  <<Patient Demographics:First Name>>	
Last Name	<<Patient Demographics:Surname>>	
Date of Birth (dd/mm/yyyy)	<<Patient Demographics:DOB>>	
Gender		

Male	

	
Other	

	

Female	

	
Address (house number, street, suburb)	<<Patient Demographics:Full Address>>	
Postcode	<<Patient Demographics:Postcode>>	
State	<<Patient State>>	
Phone*	<<Patient Demographics:Phone (Mobile)>>	
Email address*	<<Patient Demographics:E-mail>>	
Has a Mental Health Treatment Plan
been created? (Not required to refer
to MindSpot GP)		

Yes	

	

No	

Please indicate your patient’s level
of suicidal risk in the last 7 days.		

Thoughts	

	
Attempt	

	

Intent and/or plan	

	
None of the above	

	

* Please note if your patient does not have a mobile number or email address, they will miss important correspondence from
  MindSpot GP and may not be able to progress into service.

Referral Information (Optional)
Patient referred for:	  <<Patient referred for>>	
Reason for referral	

Medications (optional)		
K10-Score (optional)		
Other relevant information (optional)		

By submitting this referral, I confirm I have obtained the patient’s consent for this referral, including contact by a MindSpot GP representative by post, phone, email, or SMS. I confirm that I have discussed the MindSpot GP services with the patient and the patient meets criteria for referral. The patient has been informed that MindSpot GP will provide updates to their referring services.

Thank you for referring to MindSpot GP. We will be in touch with updates regarding your patient’s care.
Feel free to call 1800 614 434 or email contact@mindspot.org.au if you have any questions.

MindSpot GP HP Referral Form | July 2022				     Page 2