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Country & Outback Health Community Referral Form – Primary Mental Health

Please complete all information required in the form fields below

Different Postal Address?
Identify as Aboriginal or Torres Strait Islander?
Do you have an existing Mental Health Treatment Plan
Consent given for a referral to be sent to Country & Outback Health
UNDER 16 ONLY - Has Parent/Guardian consented to the referral?
Consent to share information?
Suicidal Ideation
Previous Attempt
History of Self Harm
Lives Alone
**Suicidal Intent / Plan
If yes referral not suitable for this program. Contact Mental Health Triage 13 14 65
Access to Methods
Risk to Others
Drug or Alcohol use

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