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New Patient Referral Form
Thank you for completing this online form. The information you provide here is private and confidential to Totally Psyched and will be used to ensure we capture the information we need so we might provide the most efficient process to appointment and the beginning of understanding and recovery for you and your child.
Child or Adolescent’s First Name
*
Last name
*
Date of Birth
*
Date Format: DD slash MM slash YYYY
Gender
*
Male
Female
Transgender
Non-binary
Would rather not say
Do you have someone related to your child/adolescent already being seen (now or in the past) at Totally Psyched?
*
Yes
No
Their name
How are they related?
Parent
Child
Sibling
Partner
Spouse
Other
Contact information of Parent/Guardians
Parent/Guardian 1:
Parent/Guardian 1 Name
*
Parent/Guardian 1 Phone:
*
Parent/Guardian 1 Email:
*
Physical/Postal Address
*
City
*
Country
*
Postcode
*
Parent/Guardian 2:
Parent/Guardian 2 Name
*
Parent/Guardian 2 Phone:
*
Parent/Guardian 2 Email:
*
Physical/Postal Address
*
City
*
Country
*
Postcode
*
Communication Preferences
We send out automatic reminders for upcoming appointments. These can be sent via SMS (text message) and/or Email. Which person would you like reminders sent to and how?
Name
*
Mobile
*
Email
*
Automated Reminder type
*
Email
SMS (text message)
Both
Terms
Do you agree to being sent promotional SMS marketing regarding new events
Do you agree to receive booking confirmation emails - booking confirmation emails are sent when an appointment is created. If so, please specify which email address you would like emails confirmations to go to (drop box with options: parent 1, parent 2, patient)
Billing Information
We usually expect payment on the day of appointment but sometimes (by prior arrangement) you can be sent an invoice via email for payment online. If this is the case (or you need invoices sent to a third party) who and which email address would you like invoices sent to?
Email invoice to:
Name
*
Email Address
*
If there is specific information that needs to be put on an invoice, please include this here
Other important information
School
*
School Year
*
Teacher Email address (for sending assessment questionnaires if relevant). If you do not wish us to contact your child's school teacher please leave blank and we will contact you to discuss this further if needed
Teacher’s Name (or main teacher if several)
*
Emergency contact name and phone number
*
GP Name and address
*
NHI number - if known. If not known, leave blank
Referring doctor, specialist or school staff member
Please provide details of who the referring professional is, if any are accompanying this referral.
Name
Profession
Organisation/practice name
Email
Current Concerns & Relevant Background
Please indicate if your child/adolescent has an existing mental health diagnosis made by an appropriate mental health specialist for any of the following:
ADHD
ASD
OCD
Anxiety
Depressed Mood/Depression
Tics
Tourette’s
ODD
Intellectual Disability
Eating Disorder
Psychosis
None
Other – please describe
Please indicate who made this diagnosis
Name
Profession
Please indicate if your child/adolescent has any existing specific learning disabilites identified by an appropriate specialist assessor (e.g., Educational Psychologist) for any of the following:
Writing/Dysgraphia
Math/Dyscalculia
Reading/Spelling/Dyslexia
Other – please describe
None
Please describe any previous mental health conditions diagnosed by a specialist mental health professional that are no longer current (i.e., they no longer compromise their functioning in a significant way)
Anxiety
Depressed Mood/Depression
Tics
Opposite Defiant Disorder (ODD)
Anorexia Nervosa
Bulimia
Obesity
Disordered Eating
ADHD
Autistic Spectrum Disorder (ASD)
None
Please indicate if your child/adolescent has any existing physical health conditions diagnosed by an appropriate specialist medical practitioner for any of the following:
Migraines
Enuresis (involuntary wetting)
Encopresis (involuntary bowel movements)
Crones Disease
Coeliac Disease
Chronic Fatigue
Chronic Pain
Epilepsy
Tic Disorder
Dyspraxia/Developmental Coordination Disorder
Sensory Processing Disorder
Frequent Headaches
Irritable Bowel Syndrome (IBS)
Auditory Processing Disorder
Diabetes
Other – please put details below
None
Please describe the concerns you currently have regarding your child/adolescent:
It is extremely helpful for us to be able to provide recommendations for the best psychiatrist and psychologists if we are able to obtain a brief description of your current concerns.
Please briefly describe what you are wanting or hoping to achieve by coming to Totally Psyched
*
Please describe any relevant background the clinician seeing you and your child/adolescent would find useful to know before the appointment:
Please provide information about any previous assessments that have been completed
Paediatrician letter(s)
GP Letter(s) or Referral
Educational Psychologist Report
Occupational Therapist Report
Speech and Language Therapist Report
Other – please specify
(please also email copies to referrals@psyched.org.nz)
Other
Are there currently any risk factors you are concerned about?
Please indicate if you are concerned your child/adolescent is currently at risk:
I do not feel they are currently at risk
I am concerned my child/adolescent is at risk see important information below)
If your child or adolescent is at immediate risk to themselves, to or from others, please seek help immediately by contacting your local public services, going straight to your local A&E or calling 111. Please be aware that while we are a private mental health practice we are not an emergency service. We provide assessments and therapy by appointment only and so if you are needing more care than this could provide your child, teen or family please contact your GP for further recommendations, including your eligibility and contact details for accessing your free local CAMHS (Child Adolescent Mental Health Service).
IMPORTANT: If you are concerned about your child or adolescent currently being at significant immediate risk to themselves, please immediately take them to your nearest Hospital Emergency Department for review by the psychiatric liaison team. Alternatively, contact your local Child and Adolescent Mental Health Service (CAMHS), requesting to speak with the person on ‘Duty’. The numbers for your local CAMHS are available on the
Werry Workforce website
. If a child or adolescent is at risk to or from others please immediately remove them (or the person they are harming) from any environment that may put them at risk.
Your Preferences
Please indicate if you have any preferences about a specific Group Therapy program (see 'Groups' on the website for details), a particular profession you would like to be seen by and/or any particular person you would like to see:
Group Therapy Preferences
'Lego Club' (9-12 yrs) 10 week Social Skills Group
'Wise Minds' (13-16 yrs) 8 week Emotion Regulation Group
'SAS' (Secret Agent Society) (8-12 yrs) Intensive 18 week Social Skills Group
'Parenting the ADHD Brain' 6 week Parenting Workshop
Totally Psyched also run group therapy programs for children and adolescents which can be hugely motivating for those a little reluctant or those whom social contact with others is an area of potential advancement. Please indicate your preferences if you would like to register for a group. If you would like to register for more than one or are unsure which one please indicate your preferences in order of what you think and we will discuss this with you when we call to book the group of appointment
By Profession
Psychologist (general scope)
Clinical Psychologist (clinical scope)
Child & Adolescent Psychiatrist
Paediatrician/Child & Adolescent Psychiatrist
Educational Psychologist (educational scope)
By Professional
Dr Jamie Speeden, Child & Adolescent Psychiatrist / Pediatrician
Dr Mirsad Begic, Child & Adolescent Psychiatrist
Olya Kolyaduke, Child & Family Psychologist
Dr Mnthali Price, Clinical Psychologist
Dr Sarah Watson, Clinical Psychologist / Clinic Director
Dr Camilla Nguyen, Clinical Psychologist
Dr Caroline Judson, Clinical Psychologist
Lisa Da Rocha, Clinical Psychologist / Pediatric Neuropsychologist
Paul Barber, Educational Psychologist/CBT Therapist
Dayna Cooper, Clinical Psychologist
Dr Amy Kercher, Clinical Psychologist
Medical Insurance
We are a Southern Cross Affiliated Provider and as such can process the pre-approval for you ahead of your appointment(s) with a Psychiatrist (only). You can claim for Psychologist appointments if you have Ultracare but unfortunately we are unable to do that through the pre-approval system as yet. We are working on this however. This means payment is required on the day of appointment and a claim is made by you independently. Please check if your policy covers Psychologists and if so, check if they need to be registered in the General Scope or Clinical Scope (e.g., Clinical Psychologist) and let us know so we can ensure we set you up with the relevant professional.
If a member, please provide Southern Cross details:
Policy Number
Membership Number
Terms and Conditions
What to Expect
The direction of the initial/first assessment appointment will be based on the referral information provided at the time of referral, any psychometric data collected through psychometric questionnaires by Totally Psyched as part of the collection of information done prior to an initial appointment and the information provided by those that attend the appointment. Ideally you will also get an opportunity to discuss you or your child’s goals and therapy/treatment options at this appointment. If you have any questions, please ask your specialist and they will provide a full verbal explanation at this time. A written explanation can also be provided upon request.
Consent to send out Psychometric Questionnaires to Third Parties as part of the appointment preparation process
*
In an effort to make your first initial assessment appointment as efficient as possible at times we request information from parents, young people and/or teachers through psychometric assessment questionnaires/general questionnaires in advance of the appointment. All psychometric assessments are extremely high quality evidence based, standardised, reliable and valid. Questionnaires are usually sent via secure digital portals directly to requested recipients or via post or email (if need returning urgently) and are completely confidential to our practice. We do not give out information but rather are collecting it so the Specialist has as a breadth of information to enable a quality assessment of multiple factors across multiple domains.
I agree to questionnaires being sent to my/my child’s guardians/parents, self and/or teacher if required (based on the contact information provided in this form)
I do not agree for questionnaires to be sent out to third party other than parents/guardians
I do not agree to any questionnaires being sent out at all
Consent
*
You acknowledge and accept that by ticking the box below that you have been provided an explanation as to the nature and purpose of the assessment and/or therapy proposed, and that you consent to assessment and/or therapy by us including where we provide assessment and/or therapy via the internet (for example via Skype). Where you are a child under the age of 18 we may seek the consent of your parents or legal guardians. Unless otherwise stated, in these circumstances the consent of all parents or legal guardians is required.
I confirm that I am the Client named on the Client Form and that I consent to the assessment and/or therapy proposed.
I confirm that I am the parent/guardian of the Client named on the Client Form and that I consent to the assessment and/or therapy/treatment proposed.
Name
Name
Privacy - sharing information with your GP
*
During the time you are seeing a Psychologist/Psychiatrist we develop clinical records that remain secure and completely private. After a Psychiatric assessment a letter will go out to you and your GP and after a Psychological assessment an email will be sent to you with a summary of any recommendations made and the plan developed so far, plus any resources that may be useful. After neuropsychological assessment a report is completed and sent to you to distribute as you wish and at the end of psychological therapy an End of Therapy Report is written and sent to you and your child/adolescent's GP. In NZ, your GP securely holds records of all physical and mental health summaries and is also highly confidential. Please let us know if there is any reason we should not send a copy of these summaries (not including the email) to your GP.
I consent to my/my child’s Psychiatric Assessment or End of Therapy Summary being shared with my GP
I DO NOT consent to my/my child's Psychiatric Assessment or End of Therapy Summary being shared with my GP
Privacy - sharing Neuropsychological Assessment Reports with parent/guardians
*
I consent to my/my child’s Neuropsychological Assessment Report being sent to me via email
I DO NOT consent to my/my child's Neuropsychological Assessment Report being sent to me via email
I prefer to receive the report in another form/way and will discuss this with the relevant Psychologist at our appointment
Privacy - sharing identifying information with school staff (if needed)
*
If needed, I consent to our Psychologist speaking with school staff or observing our child as part of a care and treatment plan we have discussed together
If needed, I DO NOT consent to our Psychologist speaking with school staff or observing our child as part of a care and treatment plan we have discussed together
I prefer to discus this with the Psychologist before deciding whether
Cancellation of Appointments
To cancel an Appointment you must notify us by email or telephone at least 48 hours prior to the scheduled Appointment. Cancellations notified less than 24 hours before an Appointment will incur a $90.00 cancellation fee. Cancellations notified on the day of the Appointment, or where cancellation is not notified, or an Appointment is not attended will incur the full fee for that Appointment. Notice of cancellation of an Appointment scheduled for a day immediately following a weekend or public holiday must be received by us during business hours on the day prior to the weekend or public holiday or it will be considered to be less than 24 hours notice and will incur the $90.00 cancellation fee.
Payment
Please note that payment of our fee is due on the day of your Appointment, including where relevant payment of any excess due in relation to your Southern Cross insurance policy. You accept the provision of our Terms and Conditions that allows us to charge you a $25 administration fee in addition to our other rights in collecting overdue fees.
Terms and Conditions
*
You CONFIRM that you understand and accept the Terms and Conditions of business with Totally Psyched Limited. You CONFIRM that ticking the box below that you have read our Terms and Conditions located at www.totallypsyched.co.nz, and that by consenting to assessment and/or therapy by us you agree to be bound by the Terms and Conditions. They are effective from the date of acceptance and will replace all earlier written or oral agreements and any Terms and Conditions contained in any document issued by Totally Psyched Limited and purporting to have contractual effect. Your acceptance of any services from us indicates your continuing acceptance of these Terms and Conditions.
I confirm that I understand and accept the Terms and Conditions*
Click here to read our Terms and Conditions.
Thank you for completing this pre-appointment form. We really appreciate the time you have taken to provide us with this very valuable information. Please be assured we will treat this with absolute respect and privacy.
After pressing ‘submit’ your information will be sent to our admin team and Clinic Director for processing through triage. This process can take 1-5 days, after which our friendly admin team will be in touch on the phone number(s) provided to go through our recommendations and schedule your initial appointment.
If you have any questions or queries, please contact the clinic on (09) 320 3086 or email
referrals@psyched.org.nz
. We look forward to being able to provide you with the support you and your family need and deserve. Talk soon, Sarah and the Totally Psyched Team
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