Healthy Brain Hub

Participant Details

First name

Last name

Date of birth

What is the participant’s gender?

Does the participant have access to a computer or tablet with internet connectivity? Or is someone able to provide this access for them?

Yes No

Please note that HBH is an online study, with limited capacity for in-person assessments.

What is their primary language? (please select)

Note: Primary language refers to the language they will be able to complete an assessment in.

Has the participant ever been diagnosed with moderate to severe Dementia, such that an additional cognitive assessment would not be informative to their ongoing care and management?

This includes a diagnosis of: Alzheimer’s disease, Vascular Dementia, Parkinson’s disease, Dementia with Lewy bodies or another type of dementia.

If the participant has a diagnosis of Mild Cognitive Impairment (also referred to as “MCI”), please select no.

Yes No

Is the participant currently experiencing symptoms of any of the following health conditions that require treatment? (select all that apply):

- Alcohol use disorder

- Substance use disorder

- Untreated mental health condition (e.g., Schizophrenia, bipolar disorder, major depressive disorder)

Yes No

Contact Details

Phone Number

Email Address

Does the participant currently reside in Australia?

Yes No

Is the participant aware of this referral?

Yes No

Is the participant able to be contacted directly regarding this referral?

Yes No

GP Details

GP Name

GP Clinic Name

Is the participant’s GP aware of this referral?

Yes No

Referral from Another Study

To your knowledge, is the participant being referred currently enrolled in another research study?

Referrer Information

Name

Organisation

Relationship to participant being referred

Phone Number

Email Address

Fax (if applicable)

Reason for referral (please briefly describe)

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Participant Details

Contact Details

GP Details

Referral from Another Study

Referrer Information