Norwest Wellbeing

GP / Specialist Referral Form

Clinical Hypnotherapy & Strategic Psychotherapy

Address: Nexus Building

210/4 Columbia Ct

Norwest NSW 2153

Phone: (02) 8069 9777

Email (Referrals): referrals@norwestwellbeing.com.au

Secure Messaging (Preferred)

HealthLink ID

Medical Objects ID

Referrer Details

Referrer Name

Practice

Address

Phone

Signature

Patient Details

Name

Address

Phone

Referral Details

Reason for Referral (Please tick primary concern):

Anxiety / Stress / PhobiaSmoking / Vaping CessationWomen's Health SupportPediatric Hypnotherapy 4 1/2 years upIBS (Gut-Directed)Addiction SupportAdjunctive Pain Management

Required Clinical Information: Brief summary of presenting problem, relevant history, and patient's goals

Current Medications & Allergies

Clinical Acknowledgement (Mandatory)

I confirm this referral is for non-crisis support. I acknowledge this patient does not present with acute psychosis, acute suicidality, or severe/complex personality disorder.

Important: Norwest Wellbeing is a private clinic. Mental Health Care Plans (MHCP) are not accepted. Patients may be eligible for private health fund rebates.