Complete this form, then email it to remy@monfi.com.au . You can also print and post, or hand directly to the patient to bring to the first session.
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For use by GPs, specialists, and allied health clinicians. Self-referrals and general enquiries may be submitted at monfi.com.au or by emailing remy@monfi.com.au.
1 · Referring clinician
Clinician name
Provider number (if applicable)
Practice / hospital
Discipline / role
Fax / postal address (for return correspondence, if required)
2 · Patient details
Patient full name
Date of birth
Home address (must be within Melbourne metropolitan area)
Patient phone
Patient email (optional)
Emergency contact name and phone
3 · Clinical context
Prognosis (as known / as appropriate to share)
Current treating team (please include names and specialties where known)
Reason for referral / presenting concerns
Any relevant clinical concerns (capacity, risk, mobility, communication needs, language)
4 · Funding pathway
Support at Home / Home Care Package — psychology to be funded through the patient's package budget. Package coordinator: _________________________ Phone: _________________________
Private — with Medicare rebate. Mental Health Care Plan (MHCP) attached or to follow. (Note: gap payment applies after rebate.)
Private — self-funded. No MHCP required.
Funding not yet confirmed. Please contact Remy to discuss before proceeding.
5 · Consent and declaration
Please confirm the following before submitting this referral. Monfi cannot accept referrals where patient consent has not been obtained.
The patient has been informed about this referral and has given consent to be contacted by Remy Lindner at Monfi.
The patient has been made aware that Monfi is a private service, that fees apply, and that they will be contacted to discuss the process before any sessions are confirmed.
The patient understands that Monfi is not an emergency or crisis service. If the patient has immediate clinical needs, appropriate urgent pathways have been discussed.
I consent to this referral information being held and used by Monfi for the purpose of responding to and coordinating this referral, in accordance with the Australian Privacy Principles.
Referring clinician signature
Date