Download gp referral form - Northern Melbourne Medicare Local is closed

ACCESS TO ALLIED PSYCHOLOGICAL
SERVICES (ATAPS)
GP REFERRAL FORM
Return to Infiniti Health Solutions (IHS) by fax: (03) 9354 2164 or through ATAPS Healthlink portal
For further enquiries phone: (03) 9353 4944
Referral request details:
Referral Date: <<Miscellaneous:Date>>
Please Indicate Referral Type (mandatory):
Health Care Card No <<Patient Demographics:Pension
Number>>
Referring GP: <<Doctor:Name>>
Address:<<Doctor:Address>>
Post Code: <<Doctor:Postcode>>
Islander [ ]
Ph: <<Practice:Phone>> Fax: <<Practice:Fax>>
Health Care Card Holder [ ] At Risk of Suicide [ ]
Perinatal depression [ ]
Aboriginal or Torres Strait
Affected by bushfire [ ]
Child under 12yrs [ ]
Note: The Allied Health Professional must be a registered provider with the ATAPS Program
Name of Preferred Provider: (Optional ) Note: The Allied Health Professional must be a registered provider with the ATAPS Program. Telephone:
Fax:
________________________________________________________________________
Patient details:
Patient Name: <<Patient Demographics:Full Name>>
Gender: <<Patient Demographics:Sex>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>
Telephone: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Aboriginal or Torres Strait Islander Status:
Aboriginal [ ] Torres Strait Islander [ ] Unknown [ ]
No [ ]
Main language spoken at home (only answer this question if patient
How well does the patient speak English?
has identified that they speak a language other than English)
Very Well [ ]
Well [ ]
Not Well [ ]
Not at all
[ ]
Do they require an interpreter?
Yes [ ]
Does the patient live on his/her own?
No [ ]
Yes [ ]
If yes, which language?
No [ ]
Highest level of education patient has completed:
Tertiary [ ]
Unknown [ ]
Primary [ ]
Secondary: Yr 10 [ ]
Yr 11 [ ]
Yr 12 [ ]
Additional Details:
Copy of Health Care Card attached: Yes [ ] No [ ]
Has the patient received Focused Psychological Services under Better Access in this calendar year?
Yes [
No [
]
]
Unknown [ ]
Has the patient ever received specialist mental health care before (public/private)
Yes [ ]
No [
]
Unknown [ ]
Copy of current Mental Health Treatment Plan attached
Yes [ ]
No [ ]
Does the patient have a history of violent or aggressive behaviour?
Yes [ ]
No [ ]
Unknown [ ]
ICD 10 Diagnostic Categories:
Alcohol and [ ]
Other [ ]
drug use
disorders
Psychotic [ ]
Depression [ ]
disorders
Anxiety [ ]
disorders
Suicide: Risk: Ideation: Yes [ ]
Ideation: No [ ]
Perinatal
Depression
Intent: Yes [ ]
Unexplained [
[ ]
]
Unknown [
]
somatic
disorders
Intent: No [ ]
Risk: High [ ]
Risk: Medium [ ]
Risk: Low [ ]
Which focused psychological strategy (FPS) is the patient being referred for?
Diagnostic [ ]
Psycho [ ]
Cognitive [ ]
Behavioral [ ]
Relaxation [ ]
Interpersonal [ ]
Assessment
Therapy
education
Intervention
(CBT)
Narrative [ ]
Therapy
Family Therapy [ ]
(Perinatal Depression/
Children)
Intervention
(CBT)
Strategies
Skill Training [ ]
Other CBT [ ]
(CBT)
Interv entions
(CBT)
Parent Training in Behaviour [ ]
Management (Children)
Other:[ ]..........................
please specify
Is the patient receiving psychotropic medication at referral?
Benzodiazepines / anxiolytics [ ]
Antidepressants (Incl. SSRIs, SNRIs and TCAs) [
]
Phenothiazines / Tranquilisers (resperidone, olanzapine, clozapine, [
valproate, [ ] haloperidol, chlorpromazine)
]
Mood Stabilisers (Incl. lithium carbonate, sodium
carbamazepine)
ACCESS TO ALLIED PSYCHOLOGICAL SERVICES
(ATAPS)
Patient Privacy and Consent form
This form including referral notification and consent must be returned to:
Infiniti Health Solutions (IHS by fax: (03) 9354 2164 or ATAPs Healthlink portal. Enquiries phone: (03) 9363 4944.
The patient must read and sign the consent form (below) or use verbal consent option.
Protecting your privacy and your confidential information is of the highest importance. All health care professionals, including those at Infiniti
Health Solutions and Northern Melbourne Medicare Local are bound by the Commonwealth Privacy Act 1988, which outlines the principles
concerning the protection of your personal information. Participation in this program may mean that information relating to your diagnosis and
treatment may be shared between:
 Your GP and your allied health professional;
 Others within your GP's practice;
 Others within your allied health professional's practice team; and
 Your GP, your allied health professional and members of the Infiniti Health Solutions ATAPs team.
Only information that is required for your treatment will be shared and disclosed. Any additional need to disclose your information will be
discussed with you and your individual consent obtained.
Your confidentiality will be preserved in all cases except when there is a risk to yourself or others.
Personal information including name and date of birth, and the type of mental health conceren you are experiencing will be recorded. Some
information (that will not identify you) will be provided to the Northern Melbourne Medicare Local acting on behalf of the Department of Health
and Ageing. Identifying information such as name and date of birth is not passed on.
PATIENT CONSENT
Please indicate who is consenting to collection, use and disclosure of health information.
[ ] Adult patient
[ ] Child /adolescent under 16 years (parent / guardian consent)
Patient to Complete
I agree to information about my mental health and wellbeing being collected, used and disclosed to parties identified above to assist in the
management of my health care. I understand that, at any time in my treatment, I can withdraw my consent to the collection, use and disclosure of
my information, by providing written notice to my GP, my allied health professional and to Infiniti Health Solutions. I understand that information
(that will not identify me) will be collected by Infiniti Health Solutions and used to assist in the management ad auditing of the ATAPs program
and I consent to this collection and use.
Patient Name: <<Patient Demographics:Full Name>>
<<Patient Demographics:Full Address>>
Patient Name (print clearly):
Date: <<Miscellaneous:Date>>
____________________________________________________________________________________________________
Patient Signature or
Verbal agreement given [ ]
Date:<<Miscellaneous:Date>>
___________________________________________________________________________________________________
or
Parent/ Guardian Name (print clearly):
____________________________________________________________________________________________________
Parent / Guardian Signature:
Verbal agreement given [ ]
Date: <<Miscellaneous:Date>>
____________________________________________________________________________________________________