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South Coast Private Hospital Inpatient Referral

South Coast Private admits voluntary patients that are sub-acute. For high-risk patients or acute presentations, please refer to the acute care team using the New South Wales statewide referral access number 1800 011 511 and in an emergency, call 000.

This form is for use for patients already known to the hospital, either through an admission or through the clinic.

Patient details

Patient first name

*

Patient last name

*

Patient mobile number

*

Referring psychiatrist

Psychiatrist name

*

Clinical information

Provisional diagnosis/diagnoses/issue

*

Recommended inpatient program

*

Previous inpatient programs

Nil Previous SCP admission

MAP

ACT

ER

AOD

PTSD Phase 1

PTSD Phase 2

Other SCP Program

Other Hospital

Is inpatient TMS requested as part of this admission?

*

A

Not needed

B

If possible

C

Prioritise

Documentation uploads

For example, an insurance approval request