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


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.

Client Details

Where possible, please provide

Health History

Mental Health Supports

Mental Health Diagnosis 
Has the referring client received a diagnosis? If so, please specify:

Risk Assessments
PANDA aims to provide targeted support to at-risk callers.

Please consider risk factors related to suicide, self-harm, alcohol and drugs, family violence and risk to child or infant in this referral. 

If the identified risk is formulated as HIGH, please ensure appropriate and immediate mitigation and supports are in place before making a referral.

PANDA is not a crisis service. Due to service demand, we may take several business days to attend to this referral. 

Screeners or Treatment Plans



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.