C
CI
entre for
linical
nterventions
Referral Form
•Psychotherapy•Research•Training
PATIENT DETAILS
Name
(including middle name):
M/F
Medicare No:
DOB:
Exp:
Address:
Phone No:
Mobile No:
Country of birth:
Email:
TREATMENT PROGRAMMES (Tick the programme you are referring for)
Note: CCI follows a stepped care approach. Group treatment is usually the first option considered. In certain
circumstances individual treatment may be provided. Suitability for treatment is determined via an individual assessment.
Mood Management (Depression/Anxiety)
Social Anxiety
Worry & Rumination
Bipolar Disorder (adjunctive to psychiatric management)
Other (specify below)
Eating Disorders Programme
Referrals to ED Programme have to be from a GP or
Psychiatrist. All ED treatment is individual.
Patient height:
cm
Patient weight:
kg
REFERRAL INFORMATION
PRIMARY DIAGNOSIS:
NB: Please check the inclusion & exclusion criteria for CCI referrals
REASON FOR REFERRAL:
CURRENT RISK FACTORS:
CURRENT MEDICATIONS AND DOSAGE:
(Please note any details as relevant)
(You may wish to attach a printed medication profile)
Suicide risk
Deliberate self harm
Alcohol misuse
Drug misuse
Forensic history
History of aggression
Health summary sheet attached
REFERRAL SOURCE:
Name of referrer:
Position (eg. GP, Psychiatrist)
Service:
Address:
Referral date:
/
/
Phone No:
Fax No:
Please send all referrals to the Clinic Manager at CCI, 223 James Street, Northbridge WA 6003,
or fax to (08) 9328 5911. Please call us on (08) 9227 4399 if you have any enquiries.
for
Centrelinical
C Interventions
http://www.cci.health.wa.gov.au
· Psychotherapy · Research · Training
Referrals to CCI
Who do we treat at CCI?
Inclusion criteria: Adult patients who have a clearly defined primary diagnosis in one
of the following areas…
·
Major Depression or Dysthymia
·
Bipolar Disorder (adjunctive to psychiatric management)
·
Panic Disorder/ Agoraphobia
·
Generalised Anxiety Disorder
·
Social Phobia/ Social Anxiety Disorder
·
Health Anxiety
·
Body Dysmorphic Disorder
·
Anorexia Nervosa & Atypical Anorexia Nervosa
·
Bulimia Nervosa & Atypical Bulimia Nervosa
Exclusion Criteria: Referral to CCI is not appropriate for patients who:
·
misuse alcohol or other drugs (a referral to Next Step may be more suitable)
·
have a concurrent diagnosis in the psychotic spectrum
·
are concurrently receiving treatment as an in-patient in a psychiatric hospital
·
are currently at a high risk of suicide
How do I refer to CCI?
·
CCI is a statewide service and can accept referrals from all regions.
·
Our clinic is situated at 223 James Street, Northbridge, WA, 6003.
·
To refer to CCI either use our referral form or send a referral letter including the
patient’s name, date of birth, contact details and a brief description of their presenting
concerns to Clinic Manager at CCI, 223 James St, Northbridge WA 6003 or fax on
9328-5911.
·
A clinician will then assess the person referred for suitability to join the programme
·
The patient’s needs may also be discussed directly with one of the CCI staff (MondayFriday, 9am-5pm) on 9227-4399