Medico-Legal Form

Daintree Psychiatry Medico-Legal Assessment Referral

Date

dd/mm/yyyy

This referral form is for Medico-Legal Assessments only.

By submitting this form, you acknowledge that the information gathered is accurate and your proposed client/patient is eligible for assessment from Daintree Psychiatry .

Please allow up to 24 hours to receive confirmation on whether Daintree Psychiatry can accommodate your assessment request and a further 72 business hours to receive a quote for service.

Prerequisite Information

Type of Report

In Person or Telehealth?

If this is for an injury, what was the date of the injury?

dd/mm/yyyy

Please provide a detailed explanation of your request

For example if this is an IME please specify the insurance regulatory body and assessment type. If this is another type of Medico-Legal Assessment, please provide as much detail as possible.

Client/Patient Information

Client’s Name

Client's Name

First Name

Last Name

Client’s Email

example@example.com

Client’s Phone Number

Client Address

City

State/Province

Zip/Postal

Client’s Date of Birth

dd/mm/yyyy

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

Does the client require an interpreter?

Yes

No

Preferred Contact Method

SMS

Phone Call

Email

Preferred method of contact for appointment scheduling: (This is how we will get in touch).

Daintree Psychiatry Medico-Legal Assessment Referral

Prerequisite Information

Client/Patient Information

Contact Us

Office Hours

Clinic Location

General Enquiries

Get in touch with us

Cairns

Contact Us

Clinic Location

Office Hours

Mareeba

Contact Us

Clinic Location

Office Hours

Townsville

Contact Us

Clinic Location

Office Hours

Brisbane

Contact Us

Clinic Location

Office Hours