Tel: 0299065319

[email protected]
Level 3, 30 Atchison Street

St Leonards NSW
If risk is immediate

Call Lifeline on 131114

 NEW PATIENT FORM

Request an appointment

 

Complete the new patient request form online.

This form allows us to review your situation to ensure we best serve your needs.

Please note that Dr Edirimanne, Dr Dey and Dr Mirzaie’s books are closed. All other clinicians are accepting new patients, however in most instances the wait time is currently 3-6 months.

* Once we receive the form it will take 2-3 days to call you back.  If you are not available, we will leave a message. If after 7 days you have not been back in contact with us , we will assume you no longer wish to proceed and will destroy the form.

    Patient's full name
    Patient's Date of birth (day/month/year)


    Tel/Mob
    Your E-Mail


    Name of school & class year (if applicable)
    Name of parent (s)/ guardian (s)


    Which Dr you wish to see
    Please select clinician for me


    Please provide a short summary of your situation /background


    Please indicate what you require help with:


    Is there an acute risk of suicide or harm to others what we need to be aware of?


    List previous mental health admissions and dates. If applicable.


    Please provide name of any previous professional involvements.
    Have you previously undertaken any neuro psychiatric assessments? If so are you able to supply a copy?


    TO BECOME A NEW PATIENTCLICK HERE
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