Request for services
(Referral letter template)	

Date: 

To:
[Attn]
[Address]
[Postcode]

Subject: Letter of request for services

Dear Dr

I am referring [patient’s name] for […]

I am referring [patient’s name] [date of birth] [Medicare number] for [number of sessions] sessions.

I have been [patient’s name]’s GP for the past [number of years] months/years.

In summary, the following assessment and treatment planning has been undertaken: [  ]

Mental Health Treatment Plan attached:  ☐ Yes   ☐ No

[Patient’s name] has identified the following goals as part of the attached Mental Health Treatment Plan:

[Patient’s name] has advised they would like a carer/support to be in attendance during their first session with the [service provider].

If you have any questions, please feel free to contact me directly. I can be contacted by phone on [T+00000000] and/or email at [email@email.com] if there are any queries.

[Patient’s name]’s Aboriginal Health Worker, [name], should also be contacted on [T+00000000] and/or [email@email.com].

I look forward to your reply.

Yours sincerely,

[Signature]

[GP’s name and title]

[Provider number]