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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