GP Referral
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.
Email *
GP Name: *
GP Clinic Name: *
GP Contact Number: *
Patient's Name *
Patient's Date of Birth: *
MM
/
DD
/
YYYY
Patient's Contact Number: *
Suburb or postcode where client currently lives:
Medication(s) of Concern: *
Required
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
Required
Is the patient at risk of harm to self or others?
Clear selection
If yes, please provide details:
Does your patient require an interpreter?
Clear selection
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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