PANDA Helpline Referral Form

This form is for Healthcare Providers looking to refer a person to the Helpline (noting we can only accept referrals from Healthcare Providers via this form).

PANDA takes privacy seriously, please read our Privacy Policy for more information.

If you require a completed copy of the referral for your records, please ensure you print or save a copy as a PDF.

For privacy reasons, we are not able to send identifying information about you or your client via email.

Service Eligibility

Expecting and new parents with a child up to the age of 12 months are eligible for PANDA Helpline services.

For parents of older children, please contact Parentline in your State or Territory, or the Pregnancy Birth Baby Helpline on 1800 882 436.

We only accept referrals where the client/person has provided informed consent for the referral to be completed.

Information PANDA needs from this form

Please provide as much information as possible to support triage to the right service at PANDA. Your referral must include:

Client contact details (including State/Territory location)
Perinatal status
Risk assessment
Summary of supports and reason for referral

Referrer organisation

Referrer type

Referrer job title

Referrer first name

Referrer last name

Referrer email

Referrer phone

Referrer postcode

Eligibility

What is the perinatal status of the person being referred to the PANDA Helpline?

Currently pregnant (antenatal period) Has a baby up to the age of 12 months (postnatal period)

Due date:

Date of birth of baby:

What's the main reason for making a referral today?

Where does the person being referred to the PANDA Helpline live?

Please note program availability is dependent upon the State/Territory in which the person resides. PANDA"s Intensive Care and Counselling program is only funded for VIC and QLD residents.

Postcode

Client Details

First name

Last name

Email

Where possible, please provide

Phone number

Date of birth

Gender

Aboriginal or Torres Strait Islander

Interpreter Required

YesNo

Main language spoken at home:

If other, please specify:

Consent

PANDA requires all healthcare providers submitting a referral on behalf of a patient / client to have received informed consent to share the information contained in this referral form.

I have discussed the referral with my client/patient and am satisfied they understand why information is being shared with PANDA and for what purpose. Please tick the following box to confirm.

I confirm this referral has been discussed with my client/patient and informed consent received.

I have explained to my client/patient that PANDA will contact them via the supplied phone number and my client/patient has given consent to be contacted by PANDA. Please tick the following box to confirm.

I confirm my client/patient consents to being contacted by PANDA.

My client consents to PANDA leaving messages and their preferred method is:

SMS / VoicemailEmail

Before submitting the form please confirm you consent to the following:

I consent to PANDA contacting me about this referral via the phone number provided.

I consent to PANDA leaving me a message about this referral and my preferred method is:

SMS / VoicemailEmail

Eligibility

Client Details

Health History

Consent