Download Combined GP mental health treatment plan and referral

GP Mental Health Treatment Plan and Referral Form
Date: Click here to enter text.
Dear: Click here to enter text.
Thank you for agreeing to see Enter Patient full name whom is currently a patient of mine.
Current issues:
The reason for this referral is:
Patient Assessment Information:
Patient Name:
Outcome Tool Choose scale.
Score
Enter Score
Given Names:
Surname:
DOB:
Click here to enter a
date.
Gender: Choose an item. Date:
Nationality &
Language:
Choose an Item
Language spoken at home:
English proficiency: Please select
Aboriginal or
Torres Strait
Islander:
Level of
education
Referring GP
Details:
Choose an item.
Choose an item.
GP Name:
GP Practice:
Address:
Phone:
Email:
Previous referral Previous specialist mental health care?
history:
Referral history to ATAPs? please select
Previous referral to Better Access?
Problem/Diagnosis
Number 1:
Choose an item.
Number 2:
Choose an item.
Number 3:
Choose an item.
Current Medications
Past Medical History
Current Medical History
Mental Health History/Treatment
Page 1
Yes
No
Unknown
Yes
No
Unknown
Click here to
enter a date.
GP Mental Health Treatment Plan and Referral Form
Family History
Social and Personal History
Substance Use:
Allergies and Alerts:
Relevant investigations / pathology:
attached are relevant pathology and investigation results.
Mental Status Examination
Appearance and General Behaviour (Appearance and
Mood (depressed / happiness / calm / irratibility)
Behaviour)
Thinking (Thought Content & Process (clarity/logic/flow)
Affect (blunt / congruent / lability)
Perception(Hallucinations, Illusions, Dissociation)
Sleep
Cognition (consciousness / intelligence level)
Appetite
Attention/Concentration
Motivation/Energy
Memory
Judgement (problem solving ability)
Insight (understanding & belief of illness)
Anxiety Symptoms
Orientation (Orientation to TPP)
Speech (rate / volume / pressure / tone / ease)
Risk Assessment
Suicidal Ideation
Suicidal Intent
Current Plan
Past suicide
history:
Self-harm (current
and history)
Risk to Others
(current and
history)
Key Family/Support Contact:
Phone contact:
Contact Person: Click here to enter text.
Phone number: Click here to enter text.
Page 2
GP Mental Health Treatment Plan and Referral Form
SUMMARY FORMULATION
Mental Health Plan
Problem/Diagnosis
Goal (e.g. reduce
Action/Task (e.g. psychological or pharmacological
symptoms, improve
functioning)
treatment, referral, engagement of family and other supports)
Number 1:
Choose an item.
Choose an item.
Number 2:
Choose an item.
Choose an item.
Number 3:
Choose an item.
Choose an item.
Emergency Care Important Numbers:
Plan:
Mental health advice line: 1300 280 737
Men’s Line: 1300 78 99 78
OCD & anxiety help line: 1300 269 438
Domestic Violence line: 1800 737 732
Lifeline: 13 11 14
Directline (Drug & Alcohol): 1800 888 236
Youth blue: 1300 224 636
Gambling helpline:1800 858 858
ATAPs Suicide Support Line: 1800 859 585
Suicide line: 1300 651 251
Suicide call back service (also good for carers or support persons): 1300 659 467
GP After Hours support line: 1800 022 222
GP specific instructions for crisis management:
Click here to enter text.
Finalisation of plan and referral information:
Patient Education given:
Choose an item.
Copy of MH Plan given to patient:
Yes
No
Is the patient eligible for SEMPHN
mental health program? (ATAPS)
Yes
No
If yes, please ring 1300 292 971 Intake and allocation line to get a PIN
for the patients referral.
SEMPHN PATIENT
INDENTIFICATION NUMBER (PIN):
Please enter PIN here.
Review Date:
Click here to enter a date.
Click here to enter text.
Page 3
GP Mental Health Treatment Plan and Referral Form
Consent:
Record of Patient Consent
I,
, consent to this Care Plan to proceed and I agree to information about my mental health being shared between
my GP and the counsellor to whom I am referred, to assist in the management of my health care. To enable this referral to
proceed, I agree to de-identified information to be provided to the intake line.
Signature (patient):
Date:
Click here to enter a date.
I
have discussed the proposed referral(s) with the patient and am satisfied that the patient understands the proposed uses and
disclosures and has provided their informed consent to these.
Click here to enter text.
enter a date.
GP Signature
Referring GP
Details:
Doctors Name:
Name:
Practice:
Address:
Provider No:
Page 4
Click here to