Psychiatry Referral Form For referrals to Health in Mind psychiatrists Referring Person Information Referrer Name: Practice Name: Email: Phone: HealthLink ID: Date of referral: Patient Details Patient Name: Date of Birth: Phone: Email: Parent / Guardian Details (if applicable) Parent / Guardian Name: Phone: Email: Preferred Psychiatrist Please select one of the below: Dr Leon Rajanthiran Dr Maliththa Muwanwella Dr Vijay Ganasan No Preference Referral Type / Service Requested Please select one of the following: General Adult Psychiatry Perinatal Psychiatry 291 Assessment Adult ADHD Psychiatry Addiction Psychiatry Other Reason for Referral / Relevant Clinical Information Supporting Documents Submit Referral
