SEMPHN Mental Health Referral Form (Adolescent) 2026

1. Click ‘Get Form’ to open the SEMPHN Mental Health Referral Form (Adolescent) in the editor.
2. Begin by filling out the 'Patient Details' section. Enter the patient's full name, date of birth, gender, and contact information. Indicate their mental health need level and whether they have a Health Care Card or are an NDIS participant.
3. Next, complete the 'Referrer Details' section with your full name, organization, and contact information. This ensures that communication remains clear and efficient.
4. In the 'Support Person Details' section, provide information about any support person involved in the patient's care. Include their relationship to the patient for context.
5. Proceed to fill out the 'Assessment' section. Here you will document relevant alerts and reasons for referral, along with any outcome tools used.
6. Complete the 'Patient History and Status' section by detailing diagnosis history, family history, social history, and any substance use concerns.
7. Finally, review all sections for accuracy before signing in the 'Consent' area. Ensure both patient and referrer signatures are included before submitting.

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