Clinician referral · MacMurray Clinic DGBI Program

Smart Referral Form

To be completed by the referring GP or gastroenterologist

This form captures the clinical picture needed to route your patient into the right EF Health program stream. It takes approximately 8–12 minutes to complete. Your responses are recorded securely and sent directly to the EF Health intake team.

A

Referrer and participant details

B

Presenting concerns and pressure profile

C

Stability risk flags and urgency

D

Executive functioning pain points

E

Motivation, supports, and readiness

F

Recommended stream and delivery mode

G

Consent and follow-up pathway

Section A

Referrer and Participant Details

Referring clinician

Clinician name *

Practice / clinic *

Profession / role

Contact email

Participant details

Participant full name *

Date of birth *

Contact phone

Contact email

Participant type

Referral date

Primary diagnosis

IBS — Irritable Bowel Syndrome Functional dyspepsia Functional constipation / diarrhoea SIBO / motility disorder Crohn's disease Other chronic illness / diagnosis pending

Please complete clinician name, practice, and participant name and date of birth.

Section B

Presenting Concerns and Current Pressure Profile

Primary reason for referral

What is the clinician most hoping EF Health will address?

Duration of current presentation

Current supports and previous psychology

Current treatments and supports in place

Previous psychological or program involvement

Section C

Stability Risk Flags and Urgency Indicators

Presence of any flag below does not exclude participation — it informs triage and program adaptation. Immediate escalation items are marked with !

Psychological safety and wellbeing

! Active suicidal ideation or self-harm — immediate escalation required ! Recent psychiatric admission or acute mental health episode ! Active eating disorder or significant disordered eating around DGBI management Severe depressive episode currently limiting daily functioning Panic disorder or severe health anxiety significantly amplifying presentation Trauma history directly relevant to the health or medical context Significant substance use affecting function or treatment engagement Domestic or family violence — safety planning may be required

Medical risk

! Active Crohn's flare or recent hospitalisation — medical stabilisation priority ! Significant nutritional compromise or weight concern Poorly controlled comorbidity limiting program engagement Pending or recent major surgical / procedural intervention Pregnancy — program adaptation may be required

Urgency level

Standard — routine waitlist timeframe Priority — earlier contact warranted Urgent — immediate clinician contact required before program allocation

Additional clinical notes — Section C

Section D

Executive Functioning Pain Points

Attention and focus

Difficulty sustaining attention during medical consultations or reading health information Easily distracted, loses track of what was discussed or recommended Hyperfocused on symptoms (hypervigilance) at the expense of broader functioning

Planning and organisation

Difficulty planning and preparing for appointments or procedures Struggle to organise dietary requirements, meal planning, or supplementation routines Unable to break down complex treatment plans into manageable steps Difficulty keeping track of multiple health-related tasks simultaneously

Memory and follow-through

Forgetting medications, supplements, or management strategies Losing track of symptom patterns between appointments Starting management strategies but not sustaining them Difficulty retaining health information given during consultations

Decision-making and time management

Overwhelmed by treatment decisions when multiple options are presented Avoidance of health decisions due to cognitive overload Consistently late to or missing appointments Symptom management routines disrupted by poor time management

Section E

Motivation, Supports, Barriers, and Readiness

Motivation and readiness

What does the person hope to gain from this program?

Readiness to engage

High — motivated, available, clear goals Moderate — some ambivalence or practical constraints, but engaged Low — significant ambivalence or barrier load. Preparatory contact recommended.

Available supports

Strong family or partner support Engaged with peer or community support networks Employer or school support in place Financial capacity to engage with recommended program tier Caregiver available (paediatric referral) Limited social support — isolation is a contributing factor

Known barriers

Previous negative experience with psychological or health programs Stigma around psychological support — may need normalising framing Practical barriers — transport, childcare, work hours, cost Low confidence that anything will help — learned helplessness present Cultural or language considerations Limited digital literacy — eLearning may need modification

Section F

Recommended Stream, Priority Level, and Delivery Mode

Recommended program tier

Tier 1 — Foundation Self-paced eLearning and workbook. Mild-to-moderate, high readiness, strong support. Tier 2 — Structured Program 6–10 sessions plus workbook and eLearning. Moderate-to-complex, family involvement, or paediatric. Tier 3 — Intensive Support Extended program, full suite. Complex or treatment-resistant, high context load, multi-disciplinary coordination. Undetermined — clinical review required at intake

Delivery preferences

Preferred delivery mode

Individual or family delivery

Clinical handover notes

Specific information, sensitivities, or recommendations for the intake clinician

Section G

Consent and Follow-Up Pathway

Participant consent — confirm all that apply

Participant has been informed of the EF Health program and its purpose Participant has consented to referral and sharing of relevant clinical information Participant has been given the EF Health Self-Assessment to complete prior to first appointment Participant has been informed they may withdraw at any time Parent / guardian consent obtained (paediatric referrals only)

Information sharing consent

Consent to share with referring GP Consent to share with referring gastroenterologist Participant has declined information sharing with referring clinician — noted

Follow-up pathway

Referring GP to remain in shared care — routine progress updates requested Referring gastroenterologist in shared care — updates at key milestones No active shared care required Discharge summary requested at program completion

Referrer confirmation

Referrer name (confirm) *

Date *

Provider number (optional)

Please confirm your name and the date before submitting.

✓

Referral submitted

Thank you. The referral for has been received by the EF Health intake team at MacMurray Clinic.

The team will contact the patient directly within the timeframe indicated by the priority level you selected. A copy of this referral is recorded in the clinical system.

Smart Referral Form

Referring clinician

Participant details

Primary diagnosis

Primary reason for referral

Primary pressure domains (tick all that apply)

Current supports and previous psychology

Psychological safety and wellbeing

Medical risk

Urgency level

Attention and focus

Planning and organisation

Memory and follow-through

Decision-making and time management

Motivation and readiness

Available supports

Known barriers

Recommended program tier

Delivery preferences

Clinical handover notes

Participant consent — confirm all that apply

Information sharing consent

Follow-up pathway

Referrer confirmation

Referral submitted