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Request Appointment

New Referrals Update: Thank you for your interest in our practice. Please note that we have paused accepting new referrals to our waitlist at this time. We sincerely appreciate your understanding and will update this notice when the situation changes. We look forward to welcoming new referrals in the future.

Please note: items marked * indicate mandatory fields.

Acknowledgement of Understanding

I have read and understand the Your Appointment and Fees and Payment pages. I understand that all appointments are conducted via Telehealth (Video Conference).


Personal Details

Title
Date of Birth
Day
Month
Year

Contact Details

State

Please note that the practice currently can only accept patients from NSW, VIC, and QLD due to state legislation reasons.

Please enter mobile number. No spaces please. eg. 0412345678

Private Patient Type

Please note we are a private practice, and bulk-billing services are not offered. The practice does not accept workers compensation, CTP, NDIS, veteran affairs, or medico-legal patients. If applicable, please check with your General Practitioner (GP) for alternative options.

Medical History

Diagnosed Previous or Current Conditions

Include diagnosed conditions that have previously affected, or currently do affect you. Select all that apply.

Undiagnosed Previous or Current Conditions

Include conditions that you personally believe may have previously affected, or currently affect you. Select all that apply.

Primary Conditions of current concern

Include conditions that you are currently most concerned about. Select all that apply.

Multi choice

Personal Information Confirmation

I understand that the personal information provided by this webform will be collected, held, and used in accordance with Nourishing Minds Psychiatry’s Patient Privacy policy. I confirm that I have read, consent, and agree to the Patient Privacy policy. This is in line with the Privacy Act 1988 (Cth) (‘the Privacy Act’) updated 2018.


Referral

We require an electronic copy of your referral (PDF preferred) to assess suitability for an appointment. Provide up to five relevant documents.

Provide up to five relevant documents (scanned referral, certificates etc).


Maximum 5 files.

3 MB limit.

Allowed types: jpg, jpeg, png, doc, docx, pdf.

15 MB limit per form.

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