WA Health, Government of Western Australia



|The Health (Notification of Stimulant Induced Psychosis) Regulations 2010 requires a psychiatrist who makes a diagnosis of stimulant induced psychosis in |

|respect of a patient to notify the Department of Health within 72 hours of making a diagnosis. |

| |

|Patient details |

|First name: |      |Surname: |      |DOB: |      |

|Address: |      |Suburb: |      |Postcode: |      |

|Aliases: |      |Gender: | Male | Female | Unspecified |

|Is this person of Aboriginal or Torres Strait Islander origin: |

| No | Yes, Aboriginal | Yes, Torres Strait Islander | Both Aboriginal & Torres Strait Islander |

| |

|Diagnosis |

|Diagnosis (ICD-10 code or description): |      |

|Stimulant/s precipitating diagnosis: |      |

|Access to stimulant/s: | licit illict |

|Has a urine drug screen been performed: | Yes, please attach copy | No |

| |

|Notifying psychiatrist |

|First name: |      |Surname: |      |

|Name of facility at which diagnosis was made: |      |

|Address: |      |Suburb: |      |Postcode: |      |

|Telephone |      |Fax: |      |Email: |      |

| |

|Prescriber contact |

| |

|If the patient is being treated with prescribed stimulant medicines, has the stimulant prescriber been contacted? |

| Yes | No |

| |

|Declaration |

|I hereby notify the Chief Executive Officer of the Department of Health, as required by the Health (Notification of Stimulant Induced Psychosis) Regulations |

|2010, that the abovementioned patient has experienced a psychotic episode, as per the above diagnosis, induced by or associated with the use of the stimulants |

|listed above. |

|Signature: |      |Date: |      |

| |

|Office Use Only |

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Notification

Stimulant Induced Psychosis

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