General Practitioner Referrals

General Practitioner Referral Form
Referrer Information
Name*

First NameLast Name
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Information
Name*

First NameLast Name
Date of Birth

DayMonthYear
Gender*

FemaleMaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information

Please enter at least two
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Email
Details
Has the client consented to this referral?*

Yes
Can we identify as Cancer Council Queensland when calling to make the appointment?*

YesNo
Is the client a cancer patient or other?*

Cancer PatientOther
Cancer Type*
Cancer Stage*
Cancer Phase*
Treatment*
What is the client's presenting problem?*
Please confirm that the client's concerns are related to cancer*

Yes
Please confirm that the client is not at imminent risk of suicide*

Yes
Please confirm that the client is aware that this is a short term service*

Yes
Please confirm that the client is over 18 years of age*

Yes
On a scale of 0 - 10, how has the client been feeling in the past week?*
0 - 'No distress' and 10 - 'Extreme distress'
Over the last 2 weeks, how often have you been bothered by the following problems?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Feeling nervous, anxious or on edge*

0

1

2

3

0 is Not at all, 3 is Nearly every day
Not being able to stop or control worrying*

0

1

2

3

0 is Not at all, 3 is Nearly every day
Little interest or pleasure in doing things*

0

1

2

3

0 is Not at all, 3 is Nearly every day
Feeling down, depressed, or hopeless*

0

1

2

3

0 is Not at all, 3 is Nearly every day
PHQ4 Score
If you have completed a Mental Health Care Plan for your patient to complement this referral, please upload the plan as an attachment.

Cancelof
We take privacy seriously. We are committed to respecting your privacy and protecting your personal information. Your personal information is being collected so that psychological services can be provided to you. This includes providing psychological assessment and therapy from a properly trained and suitably qualified medical professional. For more information on how we collect and handle your personal information please see our Privacy Collection Statement.
Do you accept the Privacy Collection Statement?*

I agree to Cancer Council Queensland’s Privacy Policy and Collection Statement
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General Practitioner Referral Form

Referrer Information

Client Information

Contact Information

Details

Over the last 2 weeks, how often have you been bothered by the following problems?