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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.
  • Contact information of Parent/Guardians

  • Parent/Guardian 1:
  • Parent/Guardian 2:
  • 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?
  • 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:
  • Other important information

  • Referring doctor, specialist or school staff member

    Please provide details of who the referring professional is, if any are accompanying this referral.
  • Current Concerns & Relevant Background

  • Please indicate who made this diagnosis
  • 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 also email copies to referrals@psyched.org.nz)
  • Are there currently any risk factors you are concerned about?

  • 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 the profession you would like to be seen by and/or any particular person you would like to see:
  • Medical Insurance

    We are a Southern Cross Affiliated Provider and we can process the pre-approval for you ahead of your appointment(s) with a Psychiatrist (only). You can claim for Psychologist appointments with some policies, but no pre-approval process is currently provided by Southern Cross for non-medical practitioners. 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).
  • If a member, please provide Southern Cross details:
  • If you have another medical insurance provider, please indicate below and we will happily provide digital invoice receipts for ease of speedy online claiming. Please check with your insurance company about what and which profession your policy covers prior to the appointment to avoid disappointment.
  • 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.
  • 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.
  • 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.
  • We collect private information in order to provide you with assessment and/or therapy/treatment. The private information includes that information about you that you have provided directly to us in person or through our website (“Client Details”) as well as information about you collected by us during your assessment and/or therapy (“Client Information”). From time to time during the course of your assessment and/or therapy/treatment we may need to work together with third parties in order to help make a plan for intervention and positive changes. This may include teachers, school support staff such as Counsellors/Learning Support, GPs and other professionals. By ticking the box below you consent to us sharing Client Details and Client Information with third parties when appropriate and in consultation with you or your parents.
  • 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.
  • 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.
  • 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 1-3 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.
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