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)  <Referrer Details (Required)>
First Name	
<DrFirstName>	

Last Name	
<DrSurname>	

Profession	
<Referrer Profession>	

Practice/Organisation type	
<Practice/Organisation type>	

Practice/Organisation name	
<LocationName>	

Practice/organisation address	
<DrAddress>	

Postcode	
<DrPostcode>	

State	
<DrState>	

Phone	
<DrPhone>	

Email address	
<DrEmail>	

Fax number	
<DrFax>	

Patient Details (Required) <Patient Details (Required)>
First Name	
<PtFirstName>	

Last Name	
<PtSurname>	

Date of Birth (dd/mm/yyyy)	
<PtDoB>	

Gender	
<PtSex>	

Address (house number, street, suburb)	
<PtStreet>	

Postcode	
<PtPostcode>	

State	
<PtState>	

Phone*	
H: <PtPhoneH>    W: <PtPhoneWk>    M: <PtPhoneMob>	

Email address	
<PtEmail>	

Has a Mental Health Treatment Plan been created? (Not required to refer to MindSpot GP)	
<Has a Mental Health Treatment Plan been created? (Not required to refer to MindSpot GP)>	

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

Intent and/or plan	
None of the above	

Is your patient currently experiencing hardship*? (E.g. financial, geographical, social or other accessibility disadvantage).	
<Is your patient currently experiencing hardship*? (E.g. financial, geographical, social or other accessibility disadvantage).>	

*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) <Referral Information (Optional)>
Patient referred for:	
<Patient referred for:>	

Reason for referral	
<Reason for referral>	

Medications (optional)	
<Medications (optional)>	

K10-Score (optional)	
<K10-Score (optional)>	

Other relevant information (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.