Referral Database Registration

All fields marked with an * are mandatory

Name of Agency/Service/Program/Practice (This will be the entry name) *

Contact Position/Role

Contact Title Dr Prof Mr Mrs Ms Miss

Contact First Name *

Contact Last Name *

Name of Organisation (if not stated in the Entry name)

Which categories of service do you provide for women and their families dealing with post and antenatal depression and wish to be entered into on the Database? Please select at least one service category for you entry. General Practitioner
Psychiatrist
Psychologist
Clinical Psychologist
Counsellor
Psychotherapist
Family Therapist
Social Worker
Support Group
Complementary Therapy
Education
Outreach
Family Support Service
Midwife
Doula
Child Care
Home Help
Allied Health Service
Fitness
Other
*

Other Services Offered

Appointment/Enquiries Telephone Number *

Fax

Mobile

Email (office use only) *

Verify your e-mail address *

Web Site URL

Area Served by this Service *

Detail your hours of operation *

Note: This information will only be used to give an idea of costs to assist in our referral process.

All clients will be advised to contact and discuss fees directly with the practitioner.

Cost of Service

Please provide a scale of your fees (i.e. individual, couples, family, concession)

Medicare Rebate

Out of Pocket Expences

Do you bulk bill? Yes No

Is there a rebate for your services for clients with Private Health Fund Cover? Yes No

Please nominate all initiatives your service is registered under ATAPS Better Outcomes Other

Other initiatives your service is registered under

Eligibility requirements

Is a referral required? Yes No

Is an appointment required? Yes No

Do you have a waiting list period? Yes No

Approximately how long is it?

Please describe your background and or qualifications in working with women, their partners and or families experiencing antenatal and postnatal depression.

Please provide a brief description of your Service/Agency/Program. *

Practitioners Only: What approaches or types of therapy do you use?

Are there any other services provided at your service/practice you would like to have listed?

By completing this form you maybe providing PANDA with personal information.

This information will be used solely for the purpose of referral. A full copy of PANDA's privacy policy is available on request or can be downloaded from the PANDA website.

Please read the two authorities below and uncheck if you do not consent.

Authority to list in PANDA referral database I/We give permission for my/our referral listing to be available in full on the PANDA referral database for the use of PANDA counsellors and staff only.
*

Authority to list in Victorian PND Services Directory I/We give permission for my/our referral listing to also be placed in the Victorian PND Services Directory including Name, Address, Contact Number & Brief Description.

Contact First Name

Contact Last Name

Name of Agency/Service/Program/Practice (This will be the entry name)

Number / Street Name

Suburb

State

Postcode

Number / Street Name

Suburb

State

Postcode

Appointment/Enquiries Telephone Number

Fax

Email (office use only)

Web Site URL