Ramsay Clinic Hollywood 
Entrance 5, 95 Monash Avenue 
Nedlands WA 6009
Ph: 08 9346 6803
ramsaymentalhealth.com.au	
	
Please email the completed form to RCHBookings.HPH@ramsayhealth.com.au	
Patient Information:	
Patient Surname: <PtSurname>
Patient First Name: <PtFirstName>
Patient Address: <PtStreet> <PtCity> <PtState>  <PtPostcode>
Mobile: <PtPhoneMob> 
Phone (H): <PtPhoneH>  Phone (W): <PtPhoneWk> 
Email: <PtEmail> 	DOB: <PtDoB> 
Gender: <PtSex> 
Medicare No: <PtMCNo> <PtMCLine> <PtMCExpiry>
DVA No: <PtDVANo> <PtDVACard>	
Healthfund: <PtInsFund> <PtInsNo>
Name of current Psychiatrist: <Name of current Psychiatrist (if applicable)>	
Referrer Information:	Referral Date: <TodaysDate>	
Referring Doctor: <DrName> 
Provider Number: <DrProviderNo>
Practice Name: <LocationName>   
Address: <DrStreet> <DrCity> <DrState> <DrPostcode>	Phone: <DrPhone> 
Fax: <DrFax>
Email: <DrEmail> 	
Admission Request: 	
<Admission Request>	
Reason for Referral: Inpatient (Recent history, diagnosis).	
<Reason for Referral: Inpatient>	
Reason for Referral: Day Program	
<Reason for Referral: Day Program>	
Current Management / Discharge Plan: 	
<Current Management / Discharge Plan:>	
Current Medications:	
<SelectedRx>	
Mandatory Safety Assessment: (please comment as per instruction)	
Suicide attempts or Self-Harm: <Suicide attempts or Self-Harm?>, <Comment if 'YES' to Suicide attempts or Self-Harm>
Legal Action Past / Pending: <Legal Action Past / Pending?>, <Comment if 'YES' to Legal Action Past / Pending> 
History of Aggression: <History of Aggression?>, <Comment if 'YES' to History of Aggression>
Substance Abuse: <Substance Abuse?>, <Comment if 'YES' to Substance Abuse>
Recent Fall: <Recent Fall?>, <Comment if 'YES' to Recent Fall>  
Independent with ADL's: <Independent with ADL's?>, <Comment if 'NO' to Independent with ADL's>  
Continent: <Continent?>, <Comment if 'NO' to Continent>