Thank you for contacting Northshore Kidspace.We kindly ask any new families and patients to Northshore Kidspace to please complete the form below.

To complete the form, please select the appropriate option from the drop-down menus, or enter text in the text boxes as appropriate. Please feel free to complete the form electronically and save as a PDF, or by printing and scanning.

When completed, please email the form back to

Once received, our administrative staff will forward the completed patient information form to the appropriate clinician to be reviewed. A decision will then be made by the clinician as to whether it is appropriate or not for the patient to be booked in for an initial assessment with them, or if another clinician is seen to be more suitable for the patient.

Please note that filling in and returning this new patient form does not guarantee access to treatment with a Northshore Kidspace clinician.

If the clinician you have been referred to does not have capacity, you may choose to have this form given to another Northshore Kidspace Clinician who may have capacity.

I give consent for this form to be sent to other Northshore Kidspace Clinicians:

Yes: No:

Clinical Details

Please Select / Further Details?
To which Northshore Kidspace Clinician have you been referred to OR have preference on seeing? / Please SelectAny PsychiatristAny PsychologistProf Garry WalterDr Damian FongMr Brad MarshallDr Catherine UdyDr Karyn FlowersDr Adrian FalkovMs Vanessa SpagnolDr Cecilia WanMs Anna RemondDr Kylie GullifordMs Renata Hadzic
Is the patient currently seeing a psychiatrist or psychologist?OR has previously seen any? / Please SelectYesNo
Has the patient previously been hospitalised for mental health reasons? / Please SelectYesNo
Is the patient currently taking medication? / Please SelectYesNo

Patient Information

Patient’s Name
Date of Birth
Primary contact for the Patient
Mother Name
Mother Mobile
Father Name
Father Mobile
Parent Email
Home Address
School
How did you hear about us?

Please describe your concerns, or the purpose of the referral:

Confidentiality cannot be guaranteed, as email is not a secure medium. If you complete this form and return it to Northshore Kidspace, it may contain private or confidential information. If you believe you may not be the intended recipient of this form, or if you have received this form in error, please contact the sender immediately and delete all copies. If you are not the intended recipient, you must not reproduce any part of this form or disclose its contents to any other party.

Please note that Northshore Kidspace is not a crisis service. Northshore Kidspace is not able to respond immediately to either an email or referral form requesting a service. The Northshore Kidspace administrative staff check their email periodically, but do not maintain 24-hour access to email accounts. Life threatening matters should be directed to your nearest Hospital Emergency Department or Emergency Services on 000.