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Question 1 of 9

Is this an emergency mental health problem?

Is this an emergency mental health problem?(Required)

Yes

No

Please call Triple Zero (000)

Call now

Question 2 of 9

Do you have a valid referral from a health professional?

A valid referral is a document from a GP, psychiatrist, or another health professional that allows you to claim Medicare rebates for our services.

Do you have a valid referral from a health professional?(Required)

Yes

No

A valid referral is required to see our clinicians. Please continue completing the form, and our friendly team will contact you to assist with this

Question 3 of 9

Tell us about yourself

Full Name(Required)

Age Group(Required)

Email(Required)

Phone(Required)

How did you hear about us?

Question 4 of 9

Which conditions can we help with?

Our telehealth services are designed to effectively support mild to moderate mental health conditions. If you are experiencing severe symptoms, in-person care may be more appropriate, and we can help guide you in finding the right support. Please select all that apply.

Which conditions can we help with?(Required)

ADHD

Depression

Anxiety

Bipolar Disorder

Sleep Disorders

OCD

PTSD/cPTSD

Child and Adolescent Mental Health

Other

Other - Please Specify

Question 5 of 9

Do you have a Medicare card?

Having a valid Medicare card allows you to claim rebates for eligible services with a valid referral.

Do you have a Medicare card?

Yes

No

Please Note: Without a Medicare card, you will not be eligible for Medicare rebates, and you will be responsible for the full cost of the consultation.

Please enter you Medicare number below

Medicare number(Required)

Reference number (e.g. 1,2,3)(Required)

Expiry month/year(Required)

Question 6 of 9

Is This Referral Related To Legal Cases, NDIS, Workers’ Compensation, DVA Report, or Other Complex Circumstances?

Identifying complex cases early helps direct you to the most suitable clinician.

Is this referral related to legal cases, NDIS, Workers’ Compensation, or other complex circumstances?(Required)

Yes

No

Question 7 of 9

Is a third-party organisation (e.g., DVA, NDIS or Worker’s Compensation) covering the cost of your appointment?

Payment needs to be arranged in advance, even if a third party is paying. Our friendly team can help you with this.

Is a third-party organisation (e.g., DVA, NDIS, Worker’s Compensation, or Private Insurance) covering the cost of your appointment?(Required)

Yes

No

Question 8 of 9

In The Past 24 months, Have You Seen A Psychiatrist?

This information helps us determine your eligibility for Medicare rebates.

Is a third-party organisation (e.g., DVA, NDIS, Worker’s Compensation, or Private Insurance) covering the cost of your appointment?(Required)

Yes

No

Question 9of 9

Do you have a preferred clinician?

Clinician Preference(Required)

Earliest Available

Choose a Specific Clinician

Clinician Preference

Please upload your GP referral, psychologist mental health care plan, or any other relevant documentation below.

If you don't have a referral, feel free to submit the form without it. You may upload multiple files if needed.

Please upload your referral and any additional documentation below

Drop files here or

Accepted file types: jpeg, jpg, png, pdf, Max. file size: 20 MB.

Comments

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