General Practitioner Referral Form
First Name (s): <PtFirstName>
DOB: <PtDoB>
Sex: <PtSex>	Surname: <PtSurname>
Is this an estimated DOB? <Is this an estimated DOB>	
Address: <PtAddress>
Suburb: <PtCity>                          Postcode: <PtPostcode>	
Phone (h): <PtPhoneH>
Email: <PtEmail>	Mobile: <PtPhoneMob>	
This person has or appears to have a mental illness that is severe in degree and persistent in duration: <Person has severe and persistent mental health illness>	Referring GP: 
Name: <DrName>
Phone: <DrPhone>
Fax: <DrFax>	
This person has a Mental Health Care Plan:
<Person has Mental Health Care Plan>	Email: <DrEmail>
Provider Number (if applicable): <DrProviderNo>	
Date of referral: <TodaysDate>
Reason for Referral to PIR: <Reason for referral to PIR>	
Other Notes
NDIS Participant: <NDIS participant>
Accessing a Clinical Mental Health Service: <Accessing a Clinical Mental Health Service>
Accessing Home and Community Care Services: <Accessing Home and Community Services>
Other (if applicable): <Other (if applicable)>
Please specify 'Other': <If Other, please specify>	
Preferred Lanaguage: <Preferred language>	Interpreter Required: <Interpreter required>	
Referral Form can be submitted via  Secure Fax: 08 8186 0107 or email: pir@lwb.org.au
For enquiries, or to discuss a referral, please contact Anthony Mazza (Program Manager) 08 8307 2800