For GPs and practice teams

Make a GP referral.

Complete the referral below, or send the documents you already have. Both go directly to info@axispsych.com.au.

To Brent Munro, Clinical Psychologist · Perth CBD and telehealth

Patient details

Patient name Date of birth Residential address Patient phone optional Patient email optional

Reason for referral

Tick the relevant symptoms, add a brief description, or both.

Symptoms, diagnosis or referral question optional if a symptom is selected

Current medicationsAppointment preference optional

Relevant safety information and supports optional

What does Axis need to know?

Medicare referral

This creates a referral for individual psychological therapy. The GP must have prepared or obtained the MHTP and completed the assessment and record-keeping required for that plan. This form does not replace that clinical work.

Mental Health Treatment Plan Referring practice relationship Course of treatment Individual services requested Services already used this calendar year optional Referral date

An initial course allows up to 6 individual services. Subsequent courses are limited to the remaining allocation, with a combined maximum of 10 individual services per calendar year.

I confirm an assessed mental disorder requiring at least moderate care support, the clinical need for psychological therapy, and an allocation within the applicable course and calendar-year limits. For a subsequent course, I have reviewed the patient’s need for further treatment.

MBS item information optional

An item number is not a required field on this referral. Record the item actually used in your practice software. Reviews use the appropriate general attendance item. This form does not choose or submit a Medicare claim.

MHTP preparation item

Psychological therapy items, including 80010 for an eligible in-person service and 91167 for an eligible video service, are determined by the service delivered. They do not need to be selected by the GP.

Referring GP

GP full namePractice name optional Provider number at this practicePractice phone optional Practice address

Enter the GP provider number or the practice address. You may provide both.

Remember my GP and practice details on this device. Use only on a private device. Patient details are never saved.

Documents and reply details

Attach referral, MHTP or supporting documents optional

Up to 3 PDF, JPG or PNG files, 3 MB combined. Word documents can be saved as PDF. For larger files or another format, email Axis directly. Include only documents relevant to this referral.

Reply email optional, if already included in the documents Covering message optional

Electronic signature

Your GP name will appear here.

I am the referring GP or prescribed medical practitioner. I have checked this referral and intend my name below to be my electronic signature. The patient has agreed to this referral and the sharing of the information and documents included.

Practice staff can prepare the form. The referring GP must review and sign it before submission.

By sending, you confirm you are authorised to share this information with Axis for referral and care. It is transmitted through Netlify and Resend to the Axis email inbox. These providers may process information outside Australia. Email is not end-to-end encrypted. Privacy information.

For urgent concerns, contact an appropriate acute service. This form is not monitored for emergencies. If there is immediate danger, call 000.