Download ATAPS Mental Health Referral Form Access to Allied Psychological

ATAPS Mental Health Referral Form
Access to Allied Psychological Services
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
Referring GP:
Phone:
Practice Address: (practice stamp if available)
Practice Post Code:
Name of preferred ATAPS Mental Health Professional: *If MHP is not nominated GCML will allocate to most appropriate provider
Referring GP Signature:
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.
Referral Date:
Patient Name:
DOB:
 M  F
Gender:
Address:
Postcode:
Home Ph:
Mobile Ph:
Next of Kin/Guardian:
Relationship to Patient:
 Y
Patient/Parent or Guardian provides consent for this referral:
Medicare No:
 N
Health Care/ Pension Card No:
Expiry Date:
(*Must hold one of these to be eligible for ATAPS)
Date Mental Health Treatment Plan (MHTP) Completed:
MHTP Attached:  Y
(*Must have one of these to be eligible for ATAPS)
Does the Patient speak a language other than English?  Y
If yes, how well does the Patient speak English:
Does the Patient live on their own?  Y
 N
 Very Well
Does the Patient identify as Aboriginal or Torres Strait Islander?
 Well  Not Well  Not at all
 No  Aboriginal  Torres Strait Islander  Both
 N
What is the highest level of education the Patient has completed?
 N
Does the Patient have access to transport?  Y
 N
 Primary  Year 10  Year 11  Year 12  Tertiary
Has the Patient received Better Access services this calendar year?
 Y  N
ATAPS Program Referred to: (select one)
OUTCOME TOOL SCORE:
Aboriginal & Torres Strait Islander Mental Health Service
Child ATAPS (12 years and under)
General ATAPS (Anxiety/Depression)
Perinatal Depression If Antenatal: Baby’s Due Date
If Postnatal: Infant DOB
 Suicide Prevention (non acute)
K5 Score:
SDQ Score:
K10 Score:
EPDS Score:




MSSI Score:
Suicide Prevention Referrals ONLY - ATAPS Suicide Prevention Risk Assessment
Please select rating category for each issue or attach Mental Health Service Acute Care Team, discharge summary.
Issue
Suicide / Self Harm History
Intent / Plan / Thoughts
Longstanding Problems
Psychological Factors
Lack of strengths / Support
Overall Assessment of Risk
High
High
High
High
High
High
Risk Categories
/ Moderate / Low
/ Moderate / Low
/ Moderate / Low
/ Moderate / Low
/ Moderate / Low
/ Moderate / Low
Please note:
If majority of Risk Categories are rated High
Acute Care Team referral may be more
appropriate.
Updated December 2013
Diagnosis/Presenting Complaint (please specify below)
Adjustment Disorder
Depression
Eating Disorder
Neurasthenia
Sexual Disorders
No formal diagnosis
Anxiety Disorders
Dissociative Disorder
Enuresis
Psychotic Disorders
Unexplained Somatic Disorder
Other:
Conduct Disorder
Drug & Alcohol / Substance Abuse
Hyperkinetic Disorder
Sleep Problems
Unknown
If a child is ‘at risk of’ developing any of the above, please explain under the ‘Presenting Issues’ below.
Referred for which Focused Psychological Strategies: (please specify below)
Diagnostic Assessment
Cognitive Intervention (CBT)
Skills Training (CBT)
Narrative Therapy
Family Therapy (Children)
Psycho-Education
Behavioural Intervention (CBT)
Other CBT Intervention
Is the Patient receiving Psychotropic Medication?
If yes, please indicate below:
 Benzodiazepines and Anxiolytics
 Phenothiazines and Major Tranquillisers
Interpersonal Therapy
Relaxation Strategies (CBT)
Parent Training in Behaviour Management (Children)
 Y  N
 Antidepressants
 Mood Stabilisers
Presenting issues are mild to moderate in severity?
 Y  N
Patient requires short-term psychological intervention?
 Y  N
Presenting Issues:
Patient History: (Medical, Surgical, Social & Family)
Treatment Goals:
Updated December 2013
Suicide Prevention Program Risk Assessment (Circle Issue or Example of Issue):
Issue
Examples of High Rating
Examples of Medium Rating
Suicide/Self Harm History;
Family History of suicide;
Multiple attempts of low
lethality;
 Previous attempts or exposure to
Previous attempt of high
attempts
lethality;
Repeated threats;
 Lethality
Repeated self harm.
Infrequent self harm;
Examples of Low Rating
Nil or vague thoughts;
No recent attempt of low
lethality and low
intentionality
Recent attempt of moderate
lethality.
Long standing problems;
 History of mental illness
 History of sexual/physical
abuse/neglect/domestic violence
 Family breakdown, child custody
issues
 Financial difficulties,
unemployment, homeless
 Serious physical illness/ disability
 Chronic pain or illness
Intent/Plan/Thoughts;
 Access to means
 Clear plan
 Evidence of clear intention
 Suicidal Thoughts
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
Potential access to means;
No intention to end their life
Ambivalent desire to end their
life
Psychological factors;
 Depression/hopelessness/
isolation/anger;
 Psychotic symptoms;
 Stressors in last 6 months (eg.
Recent crisis, major loss or trauma,
or anniversary)
Severe depression;
Moderate depression;
Nil or mild depression;
Command hallucinations or
delusions about dying;
Some sadness;
Nil or mild sadness;
Some symptoms of
psychosis;
No psychotic symptoms;
Preoccupied with
hopelessness, despair, feelings
of worthlessness;
Severe anger, hostility;
High level of stressors in last 6
months.
Lack of Strength & Supports;
 Availability of supports
 Stability of employment and
 Relationships
Unemployed;
Lack of supportive and stable
relationships / hostile
relationships;
Others not available or unwilling
/ unable to help.
Overall Assessment of Risk;
Clinical judgement based on the
ratings for the Issues listed above.
Most of the Issues above rate in
the High Category
Some feelings of
hopelessness;
Moderate anger, hostility;
Moderate level of stressors in
last 6 months
Employment either unstable
or unsatisfying;
Few relationships lacking
stability;
Feels hopeful about the
future;
Nil/mild anger, hostility;
Nil or mild stressors in the
last 6 months.
Stable satisfying
employment/study;
Stable relationship/s;
Others available but unwilling
/ unable to help consistently.
Support from others that are
willing and able to help
consistently.
Most of the Issues above rate
in the Moderate category.
Most of the Issues above
rate in the Low category.
Acute Care Team referral may
be more appropriate
Updated December 2013