Referral Form for Practitioners

Your form is securely submitted to the neurocare clinical team, in line with Australian Privacy Laws.

Patient details

First Name *

Surname *

Date of Birth *

Name of parent/guardian for under 18-years-old client

Phone number *

Email address *

VIC/NSW *

Our Hawthorn address is 192B Burwood Road, Hawthorn VIC 3122. We have visitor parking and are wheelchair accessible.

Which location would this patient prefer? *

Frenchs ForestSydney CBDBoth Frenchs Forest and Sydney CBD

Please select the service you are referring for *

NeurofeedbackTranscranial Magnetic Stimulation (rTMS) Neuropsychological AssessmentQEEG Brain Mapping AssessmentPsychotherapy - please note our availability for this service is limited

Please select the service you are referring for *

Referrer details

Name *

Practice Name *

Provider Number *

Date of Referral *

Please select your clinical role *

I confirm I am the referring provider as detailed here

TMS Referral

This form can only be completed by a GP or Psychiatrist.

TMS Therapy | neurocare clinics Australia

Elibility for Medicare-rebated TMS is determined by diagnosis of Treatment Resistant Depression.

Additionally, neurocare treats OCD and other conditions with TMS.

If eligible, Medicare rebates provide for 35 sessions initially, and a further 15 maintenance sessions 4 months after completing initial program if criteria is met.

TMS requires a minimum of 3 weekly sessions and approximately 20-35 sessions total for the initial program.

Reasons for TMS referral

Does this patient have treatment-resistant depression (TRD)?

Do they have other conditions? Please specify *

Other details (for Medicare eligibility):

Over 18 years

Formally diagnosed with MDD

Undertaken psychological therapy

Have not received TMS treatment previously

Failed to receive a satisfactory improvement despite trialling at least two different classes of antidepressant medication

Relevant history

History of seizures or epilepsy

History of bipoloar disorder or affective switching

Neurological infection

History of brain trauma

History of headache or migraine

History of tinnitus

History of dizziness or syncope

Alcohol or other substance misuse

Pregnant or planning pregnancy

Presence of a cochlear implant, pacemaker, or other implanted metal/electronic device

Please provide any further notes as applicable

Please upload your official detailed psychiatry referral letter for this patient *

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Please upload a Mental Health Care Plan for the TMS initial (optional)

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Neurofeedback Referral

This form can only be completed by a GP.

A Mental Health Care Plan is optional but preferable, to gain rebates on up to 10 sessions.

Neurofeedback is a "brain-training" therapy backed by research to improve focus, self-regulation, and sleep. A short-term treatment for ADHD and insomnia with long-lasting effects, it can also benefit those with other conditions seeking improvement.

Clients attend 2 sessions per week for 10-20 sessions. Additional sessions can be recommended. Telehealth sessions are available.

Before treatment, our clincians will start with a thorough assessment of wellbeing including a QEEG to personalise the Neurofeedback protocol.

Reason for seeking Neurofeedback treatment *

Please upload the Mental Health Plan to access Medicare rebates *

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Neuropsychology & QEEG Brain Mapping Assessments

This form can only be completed by a GP.

A Mental Health Care Plan is optional but preferable, to gain rebates on the initial and feedback sessions.

Assessment options available are listed here.

The clinician will conduct an initial assessment in the first session to determine the assessment suitable for your patient.

This form can only be completed by a GP.

A Mental Health Care Plan is optional but preferable, to gain rebates on the initial and feedback sessions.

Assessment options available are listed here.

The clinician will conduct an initial assessment in the first session to determine the assessment suitable for your patient.

This form can only be completed by a GP.

A Mental Health Care Plan is optional but preferable, to gain a rebate on the initial session.

Assessment options available are listed here.

The clinician will conduct an initial assessment in the first session to determine the assessment suitable for your patient.

This form can only be completed by a GP.

A Mental Health Care Plan is optional but preferable, to gain a rebate on the initial session.

Assessment options available are listed here.

The clinician will conduct an initial assessment in the first session to determine the assessment suitable for your patient.

Reason for seeking neuropsychological or QEEG brain mapping assessment *

Please upload a Mental Health Care Plan to access Medicare rebates on the initial and feedback sessions (optional)

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Psychotherapy Referral

This form can only be completed by a GP.

A Mental Health Care Plan is optional but preferable, to gain rebates on 10 sessions per calendar year.

Psychotherapy in Melbourne is very limited and may have a wait-list. Our neuropsychologists are very experienced in talk therapies and neuromodulation; our research shows that when psychotherapy is integrated within our digital therapy programs, there is a greater chance of achieving full remission of symptoms.

We appreciate your patience.

This form can only be completed by a GP.

A Mental Health Care Plan is optional but preferable, to gain rebates on 10 sessions per calendar year.

Our clinical team in Sydney is listed here.

Primary reason for seeking psychotherapy *

Please upload a Mental Health Care Plan *

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Psychiatry - Dr Taggart Lidbury

Dr. Taggart Lidbury | Psychiatrist at neurocare Frenchs Forest

Dr Lidbury has a special interest in helping patients with substance use disorders and addictions as well as trauma, anxiety, mood disorders and ADHD.

Please upload your detailed psychiatry referral *

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Signature of referrer *

Clear

Please submit the form when complete.

Thank you.