Medicare Mental Health Plan Referral

Medicare card representing Medicare Referrals to manage various psychological conditions

The Psychologists at Paragon PsychConnect can assist your patients to develop adaptive strategies to manage various psychological conditions under Medicare.

Please complete the form below and we will contact you to discuss your client's needs.

Once you complete the form and press “Submit Referral Form”, the form will be sent to us and emailed to you as an attachment.

Alternatively, you can fax or ring our office to make an appointment.

If you cannot complete the online form below, please go to Referral Forms to download a pdf form that you can fill in, and either email it to us or bring it with you, to assist us with your initial appointment.

Referral Form Medicare Mental Health Plan

Client Details
Referrer Details
Submit Form

Medicare Mental Health Plan Referral Form

Client Details

Client Title

Mrs

OtherOther

Client Date of Birth

Age (Years)

Client First Name *

Client Last Name *

Client Preferred First Name

Client Gender Client Gender

Client Home Phone

Client Mobile Phone *

Client Email Address

Confirm Client Email Address

Client Address *

Client Address

Emergency Contact Name

Emergency Contact Phone

Guardian/Caregiver Name (if applicable)

Guardian/Caregiver Phone

Centrelink (Job Seeker, Disability Support Pension, Aged Care Pension)

Yes

Medicare Mental Health Plan Referral

Medicare Mental Health Plan Referral Form

Client Details

303 Payneham Road Royston Park SA 5070

+61 (8) 7095 3484

+61 (8) 7095 3485

Email

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