New Patient Referral – Mental Healthcare for Families, Kids, and Teens

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*

Gender*

Male
Female
Transgender
Not applicable

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?

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*

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)

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:

Current concerns

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

Please indicate if your child/adolescent has any existing physical health conditions diagnosed by an appropriate specialist medical practitioner for any of the following:

Please describe

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)

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 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)

I am concerned my child/adolescent is at risk in the following way(s):

To themselves (i.e., potentially significantly hurting themselves)
To others (i.e., potentially or is currently significantly hurting others)
From another person (i.e., potentially someone else is harming them)

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:

By Profession

Psychologist (general scope)
Clinical Psychologist (clinical scope)
Child & Adolescent Psychiatrist
Paediatrician & Child & Adolescent Psychiatrist

By Professional

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:

Policy Number

Membership Number

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.

Email invoice receipts to

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*

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)

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

Privacy*

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.

I confirm that I consent to my/my child’s client information being shared with appropriate third parties as necessary.

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 1-3 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.

New Patient Referral Form

Contact information of Parent/Guardians

Communication Preferences

Billing Information

Other important information

Referring doctor, specialist or school staff member

Current Concerns & Relevant Background

Are there currently any risk factors you are concerned about?

Your Preferences

Medical Insurance

Terms and Conditions