Referral form and eligibility criteria for Monarch Emerge

Patient First Name *

Patient Last Name *

Patient Email Address

Patient contact number

First name of referring person *

Last name of referring person *

Email of referring person

Contact number of referring person

Monarch Emerge is a 24 week mental health program for people experiencing depression and anxiety and offers psychological and psychiatric care, group sessions, a self paced skills course and care co ordination. The first phase of the program (first 12 weeks) involves weekly counselling sessions, and the second phase (second 12 weeks) the counselling sessions become fortnightly. There are monthly group therapy sessions and monthly psychiatric reviews. The therapist will liaise with external care providers including treating GP.

I have discussed the referral with the patient and they consent to the referral being made *

YesNo - Please briefly discuss the program with the patient first and obtain permission before proceeding with this referral

People who meet the following criteria are eligible for Monarch Emerge

Individuals aged 18 or above

Individual wishes to engage in psychological and psychiatric care

Persons with reliable internet and telephone connection, and access to a private/confidential space for virtual sessions

Experiencing symptoms of depression and / or anxiety

Person is planning on residing in Australia as an outpatient for the 24 week program

Based on the above criteria is the person eligible for Monarch Emerge? *

YesNo

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