Referral For Examination By Psychiatrist
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1
2Please use ID label or block print
CHIEF PSYCHIATRIST
FAMILY NAME
UMRN
Please use ID label or block print
Please use ID label or block print
CHIEF PSYCHIATRIST
CHIEF PSYCHIATRIST
OF
FAMILY NAME
UMRN
FAMILY NAME
UMRN
OF
GIVEN NAMES
CMHI
WESTERN AUSTRALIA
OF
WESTERN AUSTRALIA
GIVEN NAMES
CMHI
WESTERN AUSTRALIA
GIVEN NAMES
CMHI
BIRTHDATE
GENDER
WA MENTAL HEALTH
BIRTHDATE
GENDER
WA MENTAL HEALTH
ACT 2014
WA MENTAL HEALTH
BIRTHDATE
GENDER
ACT 2014
ACT 2014
ADDRESS
ADDRESS
SECTIONS: 26, 31, 36, 37, 41, 42
ADDRESS
SECTIONS: 26, 31, 36, 37, 41, 42
SECTIONS: 26, 31, 36, 37, 41, 42
FORM 1A - REFERRAL FOR EXAMINATION BY PSYCHIATRIST
FORM 1A - REFERRAL FOR EXAMINATION BY PSYCHIATRIST
FORM 1A - REFERRAL FOR EXAMINATION BY PSYCHIATRIST
Assessment completed:
Date:
DD/MM/YY
Time:
HH:MM
Assessment completed:
Date:
DD/MM/YY
Time:
HH:MM
Place: _______________________________
(If AV used, place of assessment is referred person’s location.)
Place: _______________________________
Metro area
Non-metro area
(For non-metro there is possibility of extending referral - see Form 1B.)
(If AV used, place of assessment is referred person’s location.)
Metro area
Non-metro area
(For non-metro there is possibility of extending referral - see Form 1B.)
Basis on which it is suspected that the person needs an involuntary treatment order:
Basis on which it is suspected that the person needs an involuntary treatment order:
Distinguish whether information obtained from referred person, their medical record or another person.
Distinguish whether information obtained from referred person, their medical record or another person.
Refer to Form 1A Attachment if required.
Refer to Form 1A Attachment if required.
Referred person is to be examined at:______________________________________________
Referred person is to be examined at:______________________________________________
Authorised hospital
Other place
Authorised hospital
Other place
I certify that I have assessed the person being referred and, having regard to the criteria in section 25 of the
I certify that I have assessed the person being referred and, having regard to the criteria in section 25 of the
Mental Health Act 2014 (see overleaf), reasonably suspect that the person: is in need of an involuntary
Mental Health Act 2014 (see overleaf), reasonably suspect that the person: is in need of an involuntary
treatment order; or is on a community treatment order and is in need of an inpatient treatment order.
treatment order; or is on a community treatment order and is in need of an inpatient treatment order.
Name of referring practitioner: ___________________________________________________
Name of referring practitioner: ___________________________________________________
Qualifications: ___________________________
Signature:___________________________
Qualifications: ___________________________
Signature:___________________________
Medical practitioner AMHP
Medical practitioner AMHP
Date and time referral made:
Date:
DD/MM/YY
Time
HH:MM
:
Date and time referral made:
Date:
DD/MM/YY
Time
HH:MM
Must be within 48 hours of (or if referring voluntary inpatient at authorised hospital, immediately after) assessment.
:
Must be within 48 hours of (or if referring voluntary inpatient at authorised hospital, immediately after) assessment.
Date and time referral will expire:
Date:
DD/MM/YY
Time
HH:MM
:
Date and time referral will expire:
Date:
DD/MM/YY
Time
HH:MM
72 hours after referral made. This may be extended under Form 1B.
:
72 hours after referral made. This may be extended under Form 1B.
REVOCATION OF REFERRAL (If required)
REVOCATION OF REFERRAL (If required)
Reason for revoking referral:
Reason for revoking referral:
I am satisfied that the referred person is no longer in need of an involuntary treatment order.
I am satisfied that the referred person is no longer in need of an involuntary treatment order.
Is the referral being revoked by the practitioner who made the referral?: Yes
No
Is the referral being revoked by the practitioner who made the referral?: Yes
If No, practitioner who made referral must be consulted. Provide details of the consultation, or, if the referring
No
practitioner could not be contacted, a record of the efforts to do so:
If No, practitioner who made referral must be consulted. Provide details of the consultation, or, if the referring
practitioner could not be contacted, a record of the efforts to do so:
Name of revoking practitioner: _______________________________ Date:
DD/MM/YY
Time:
HH:MM
Name of revoking practitioner: _______________________________ Date:
DD/MM/YY
Time:
HH:MM
Qualifications: ________________________________ Signature:_____________________________
Qualifications: ________________________________ Signature:_____________________________
Medical practitioner AMHP
Medical practitioner AMHP
Receival at place of examination:
Receival at place of examination:
Date:
DD/MM/YY
Time
HH:MM
Signature:
:
Date:
DD/MM/YY
Time
HH:MM
Signature:
:
November 2015
November 2015
Page 1 of 2
November 2015
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