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Transcript
ATAPS Mental Health Referral Form Access to Allied Psychological Service (ATAPS) Forward completed referral form together with the Mental Health Treatment Plan to Gold Coast Medicare Local: via Medical Objects (GCML Referrals) or Fax: 07 5612 5499 ATAPS Program Referred to: <<ATAPS Program Referred to:>> Referral Date: <<Miscellaneous:Date (short)>> Referring GP: <<Doctor:Name>> Practice Name: <<Practice:Name>> Practice Address: <<Practice:Address>> Practice Phone No: <<Practice:Phone>> Name of preferred ATAPS Mental Health Professional: <<Name of preferred ATAPS Provider:>> *If MHP is not nominated GCML will allocate to most appropriate provider Please note: One referral = 6 sessions. A Patient must be reviewed by the GP before a further 6 sessions can be provided. The subsequent allocation of 6 sessions requires an ATAPS Mental Health Review Form to be completed. Patient Details: Patient Name: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>> Gender: <<Patient Demographics:Sex>> Address: <<Patient Demographics:Full Address>> Home Phone No: <<Patient Demographics:Phone (Home)>> Mobile Phone No: <<Patient Demographics:Phone (Mobile)>> Patient/Parent or Guardian provides consent for this referral: <<Patient/Parent or Guardian Consent obtained?>> Medicare No: <<Patient Demographics:Medicare Number>> Health Care / Pension Card No: <<Patient Demographics:Pension Number>> Date Mental Health Treatment Plan (MHTP) Completed: <<Date Mental Health Treatment Plan completed: >> MHTP attached: <<Mental Health Treatment Plan attached:>> Doesthe Patient speak a language other than English: <<Does patient speak a language other than English:>> If yes, what language/s: <<If yes, what language/s: >> How well does the Patient speak English: <<How well does patient speak English: >> Does the Patient identify as Aboriginal &/or Torres Strait Islander: <<Identify as Aboriginal or Torres Strait Islander:>> Does the Patient live on their own: <<Does the patient live on their own:>> Does the Patient have access to transport: <<Does the patient have access to transport: >> What is the highest level of education the patient has completed: <<Highest level of education completed: >> Has the Patient received Better Access services this calendar year: <<Better Access services received this calendar yr?>> Outcome Tool Used and Score: Aboriginal & Torres Strait Islander MHS - K5 Score: <<Aboriginal and Torres Strait Islander K5 Score: >> Child ATAPS (12 years and under) - SDQ Score: <<Child ATAPS - SDQ Score: >> General ATAPS (Anxiety/Depression) - K10 Score: <<General ATAPS - K10 Score>> Perinatal Depression (child up to 1yr old) - EPDS Score: <<Perinatal Depression - EPDS Score>> If Antenatal: Baby's Due Date: <<If Antenatal - Baby's Due Date>> If Postnatal: Baby's DOB: <<If Postnatal - Baby's DOB:>> Sucide Prevention: <<Suicide Prevention - MSSI Score:>> Suicide Prevention Referrals ONLY - ATAPS Suicide Prevention Risk Assessment Issue Suicide / Self Harm History Intent / Plan / Thoughts Longstanding Problems Psychological Factors Lack of strengths / Support Overall Assessment of Risk Risk Categories <<Suicide/Self Harm History>> <<Intent/Plan/Thoughts>> <<Longstanding Problems>> <<Psychological Factors>> <<Lack of strengths/Support>> <<Overall Assessment of Risk>> Please note: If majority of Risk Categories are rated High Acute Care Team referral may be more appropriate. Updated December 2013 Diagnosis/Presenting Complaint: Adjustment Disorder <<Adjustment Disorder>> Depression: <<Depression>> Eating Disorder: <<Eating Disorder>> Neurasthenia: <<Neurasthenia>> Sexual Disorders: <<Sexual Disorders>> No formal diagnosis: <<No formal diagnosis>> Anxiety Disorders<<Anxiety Disorders>> Conduct Disorder: <<Conduct Disorder>> Dissociative Disorder: <<Dissociative Disorder>> Enuresis: <<Enuresis>> Drug & Alcohol/Substance Abuse: <<Drug and Alcohol /Substance Abuse>> Hyperkinetic Disorder: <<Hyperkinetic Disorder>> Sleep Problems: <<Sleep Problems>> Unknown: <<Unknown>> Psychotic Disorder: <<Psychotic Disorder>> Unexplained Somatic Disorder: <<Unexplained Somatic Disorder>> Other: <<Other: >> If this is a Child ATAPS referral, is the child 'at risk of' developing a disorder? <<Child at risk of developing a disorder, please explain>> Referred for which Focused Psychological Strategies: Diagnostic Assessment: <<Strategy Psycho-Education: <<Strategy - Psycho Interpersonal Therapy: <<Strategy Diagnostic Assessment:>> Education:>> Interpersonal Therapy: >> Cognitive Intervention (CBT): <<Strategy Behavioural Intervention (CBT): <<Strategy Relaxation Strategies (CBT): <<Strategy Cognitive Intervention (CBT): >> Behavioural Intervention (CBT):>> Relaxation Strategies (CBT):>> Skills Training (CBT): <<Strategy - Skills Other CBT Intervention: <<Other CBT Intervention: >> Training (CBT): >> Narrative Therapy: <<Strategy - Narrative Therapy: >> Family Therapy (Children): <<Strategy - Family Therapy (Child Only):>> Parent Training in Behaviour Management (Children): <<Strategy: Behaviour Management (Child Only)>> Is the Patient receiving Psychotropic Medication? <<Is the Patient receiving Psychotropic Medication?>> Benzodiazepines and Anxiolytics: <<Benzodiazepines and Antidepressants: <<Antidepressants?>> Anxiolytics?>> Phenothiazines and Major Tranquilisers: <<Phenothiazines and Mood Stabilisers:<<Mood Stabilisers?>> Major Tranquilisers?>> Presenting issues are mild to moderate in severity? <<Presenting issues are mild to moderate in severity?>> Patient requires short-term psychological intervention? <<Requires short-term psychological intervention?>> Presenting Issues: <<Presenting Issues>> Patient History (Medical, Surgical, Social & Family): <<Patient Hsitory (Medical, Surgical, Social & Family)>> Treatment Goals: <<Treatment Goals>> Updated December 2013 Risk Assessment (Circle Issue or Example of Issue): ONLY Required for SUICIDE PREVENTION REFERRALS Issue Examples of High Rating Examples of Medium Rating Examples of Low Rating Suicide/Self Harm History: Family History of suicide Multiple attempts of low Nil or vague thoughts lethality Previous attempts or Previous attempt of high No recent attempt of low exposure to attempts lethality Repeated threats lethality and low intentionality Lethality Repeated self harm Infrequent self harm Recent attempt of moderate lethality Long Standing Problems: History of metnal illness History of sexual/physical abuse/neglect/domestic violence Family breakdown, child custody issues Financial difficultities, unemployment, homeless Serious physical illness/disability Chronic pain or illness Intent/Plan/Thoughts: Access to means Clear plan Evidence of clear intention Suicidal thoughts Psychological Factors: Depression/hopelessness/ isolation/anger Psychotic symptoms Stressors in last 6 months (eg recent crisis, major loss or trauma, or anniversary Several factors in this list are involved Some factors in this list are involved Nil or one factor in this list are involved Continual/specific thoughts Frequent thoughts Nil or vague thoughts Evidence of clear intention A plan that is not fully developed No real plan Access to means A well developed plan Overall Assessment of Risk: Clinical judgement based on the ratings for the Issues listed above No intention to end their life Ambivalent desire to end their life Severe depression Moderate depression Nil or mild depression Command hallucinations or delusions about dying Some sadness Nil or mild sadness Some symptoms of psychosis Preoccupied with Some feelings of hopelessness hopelessness, despair, feelings Moderate anger, hostility of worthlessness Moderate level of stressors in Severe anger, hostility last 6 months High level of stressors in last 6 months Lack of Strength & Supports Unemployed Availability of supports Stability of employment and relationships Potential access to means Lack of supportive and stable relationships/hostile relationships No psychotic symptoms Feels hopeful about the future Nil/mild anger, hostility Nil or mild stressors in the last 6 months Employment either unstable or Stable satisfying unsatisfying employment/study Few relationships lacking stability Others not available or unwilling/unable to help Others available but unwilling/unable to help consistently Most of the Issues above rate in the High Category Most of the Issues above rate in the Moderate Category Stable relationship/s Support from others that are willing and able to help consistently Most of the Issues above rate in the Low Category Consider if Acute Care Team referral is appropriate Updated December 2013
