Please enter referral details below. You will receive a copy of the referral via email for your records.
If you have informed consent from your patient, the MSRS Intake Worker will contact your patient within 2-3 business days. We will also advise you once we have made contact with your patient.
GP Clinic Name:
GP Contact Number:
Patient's Date of Birth:
Patient's Contact Number:
Suburb or postcode where client currently lives:
Medication(s) of Concern:
Eugeroics (wake-promoting medication)
Sedative-hypnotics ('Z drugs')
Consent Obtained for Referral
*Please note: we can't proceed with referrals if the client hasn't provided consent. To speak with us about this, call 1800 931 101
Yes - my patient has provided informed consent and would like the MSRS Intake Worker to contact them directly.
No - my patient has not provided informed consent for the referral.
Is the patient at risk of harm to self or others?
If yes, please provide details:
Does your patient require an interpreter?
How did you hear about us?
Thank you for your referral to the MSRS. You will receive a copy of your referral via email. The MSRS Intake Worker will contact your patient within 2-3 business days and advise you of the referral outcome.
A copy of your responses will be emailed to the address you provided.
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