Form 002 29 Sep, 2024 M&B Form 002 Referral Upload Upload your referral here. This field is hidden when viewing the formServiceadhdasdcombinedtmspsychologypsychiatryfunctionalDo you live in Western Australia?(Required) Yes No Are you looking for an ADHD assessment?(Required) Yes No Would you like to see a psychologist?(Required) Yes No Would you like to start TMS Treatment?(Required) Yes No Do you currently have a referral?(Required) Yes No Has your GP already sent a referral to Mind & Brain?(Required) Yes No Name(Required) First Last Email(Required) Date of Birth(Required) DD slash MM slash YYYY Mobile(Required)GP DetailsGP Name(Required)GP Practice(Required)Referral Upload(Required) Drop files here or Select files Max. file size: 30 MB, Max. files: 3. Questionairre(Required)YesNoHave 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 prescribed and non-prescribed?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?(Required)YesNoHave you had TMS before?Are you aged 18 or above?Have you been diagnosed with Depression?Have you ever been treated with antidepressants?Have you ever had psychological treatment?Have you ever received treatment for substance useHave you ever been diagnosed with Epilepsy?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 ConditionsEmailThis field is for validation purposes and should be left unchanged.
