Form 002 by Chase | 29 Sep, 2024 M&B Form 002 Referral Upload Name(Required) First Last Email(Required) Date of Birth(Required) DD slash MM slash YYYY Phone(Required)Basic Information(Required)Basic InformationYesNoResident of Western AustraliaMy Referral has already been sent to Mind & Brain by my GPGP Name(Required)GP Practice(Required)Referral Upload(Required) Drop files here or Select files Max. file size: 30 MB, Max. files: 3. Triage(Required)TriageYesNoHave you ever been diagnosed with any major mental condition such as Schizophrenia or Bipolar Affective Disorder?Have you been diagnosed with personality Disorder?Have you ever been diagnosed with Anorexia Nervosa and currently experiencing problems maintaining weight?Have you ever attempted suicide?Have you been admitted to a psychiatric hospital?Have you ever received treatment for substance useDo you currently use any illicit substances including cannabis?In the last 12 months, have you been taking medication for ADHD?Do you drink alcohol excessively?Do you have history of violence or legal problems?Is anyone from your family attending Mind and Brain Clinic?Please provide details if you answered yes to any of the above questions(Required)Terms and Conditions(Required)For emergency care or in a life-threatening situation, call 000 or present to your nearest emergency department. Crisis support is also available through Lifeline on 13 11 14 or the Mental Health Emergency Response Line on 1300 555 788. Further useful information can be found at https://www.yourhealthinmind.org. Do not use this enquiry form in a crisis. Responses may take up to 5 business days. By submitting this form you agree to these conditions. I accept the Terms and ConditionsNameThis field is for validation purposes and should be left unchanged.