<<Addressee:Full Details>>			<<Miscellaneous:Date>>

RE: <<Patient Demographics:Full Name>>

Thank you for seeing <<Patient Demographics:First Name>>, who is currently a patient of mine.
<<Patient Demographics:First Name>> is currently experiencing: 

The reason for this referral is:  <<Reason for referral>>. The following is the patient's recent GPMHTP for consideration.

PATIENT DETAILS:	
Patient Name 	<<Patient Demographics:Full Name>>	
Assessment Date 	<<Miscellaneous:Date (long)>>	
Address	<<Patient Demographics:Address>>	
Phone:	<<Patient Demographics:Phone (Home)>>
<<Patient Demographics:Phone (Mobile)>>	
DOB 	<<Patient Demographics:DOB>>	
Gender 	<<Patient Demographics:Gender>>	
Culture & language 	<<Patient Demographics:Language Preferred>>
<<Patient Demographics:Language Spoken>>	
GP 	<<Doctor:Full Details>>	
Significant support person	<<Identified parent / support>>	
Medicare card Number 	<<Patient Demographics:Medicare Number>>	
Health care card number	<<Patient Demographics:Pension Number>>	

PATIENT HISTORY - GENERAL	
Clinical History	
<<Clinical Details:History List>>	
Medications	
<<Clinical Details:Medication List>>	
Allergies	
<<Clinical Details:Allergies/Adverse Reactions>> 	
Family History	
<<Clinical Details:Family History>> 	
Significant cultural factors	
<<Patient Demographics:Ethnicity>> 	

PSYCHO-SOCIAL ASSESSMENT - HEADSS	
H – Home situation: 	
<<Home (Consider - living arrangments, risks, abuse)>> 	
E – Education, Employment, Eating, Exercise:	
 <<Education, Employment, Eating, Excercise>>	
A – Activities, Hobbies & Peer Relationships:	
<<Activities, Hobbies & Peer Relationships>>	
D – Drug Use:	
 <<Drug use / alcohol / cigerettes / caffeine drinks.>>	
S – Sexual Activity & Sexuality	
<<Sexual activity and sexuality.>>	
S – Suicide, Depression & Mental Health, Safety/Risk:	
Refer to mental status and risk assessment below:	
K10+ outcome tool & result (if appropriate):	<<K10+ score>>	
MENTAL STATUS EXAMINATION	
Appearance and general behaviour	<<Appearance and general behaviour>>	Mood	<<Mood  (Depressed / Labile )>>	
Thinking 	 <<Thinking (Content / Rate / Disturbances)>>	Affect 	<<Affect  (Flat / Blunted)>>	
Perception	<<Perception  (Hallucinations etc)>>	Sleep	<<Sleep (Initial Insomnia / Early Morning Wakening)>>	
Cognition	<<Cognition  (Level of consciousness/ delirium / intelli>>	Appetite  	<<Appetite  (Disturbed Eating Patterns)>>	
Attention / Concentration	<<Attention and concentration>>	Motivation & energy	<<Motivation and energy>>	
Memory	<<Memory (Short & Long term)>>	Judgment	 <<Judgment (Ability to make rational decisions)>>	
Insight	<< Insight>>	Anxiety symptoms	<<Anxiety Symptoms (Physical & Emotional)>>	
Orientation 	<<Orientation (Time / place / person)>>	Speech  	 <<Speech  (Volume / Rate / Content)>>	

RISK ASSESSMENT	
Suicidal ideation	<<Suicidal ideation>>	
Suicidal intent	<<Suicidal intent>>	
Current plan	<<Current suicide plan and means >>	
Risk to Others	<<Risk to others>>	
Other risk issues identified:	<<Other risk issues identified:>>	
	
CARE PLAN	
PROBLEM / ISSUE	GOAL	ACTION	
<<Problem / issue 1>>	<<Goal 1>>	<<Action 1>>	
<<Problem / issue 2>>	<<Goal 2>>	<<Action 2>>	
<<Problem / issue 3>>	<<Goal 3>>	<<Action 3>>	

CRISIS PLAN / EMERGENCY PLAN	
Specific crisis management instructions: 	<<Specific crisis management plan instructions:>>	
GP practice number:	<<Practice:Phone>>	
GP after hours call line:	1800 022 222	

GENERAL SUPPORT SERVICES	
Websites	Smart phone Apps	Phone support	
The Brave Program (Anxiety)
https://brave4you.psy.uq.edu.au/ 
Reach Out    https://au.reachout.com/ 
Bite Back     https://www.biteback.org.au/ 
eHeadspace
https://www.eheadspace.org.au/ 
Youth Beyond Blue
https://www.youthbeyondblue.com/  	Smiling Mind
Mind the Bump
Worry Time
The Desk	Emergency:  000            
Lifeline:         13 11 14
Kids helpline: 1800 55 1800
Youthblue:  1300 224 636
Women’s support line:     1300 134 130
Safesteps (family violence)     1800 015 188
Domestic violence line:     1800 737 732 BraveHearts 24hrs:      1800 272 831
Suicide line 1300 651 251
Suicide call back line  1300 659 467	

REFERRAL INFORMATION	
Date of Mental Health Plan Review:	 <<Date of Mental Health Plan Review: >>	
Patient education provided:	<<Patient information given>>	
Copy of MH plan provided to patient:	<<Copy of MH plan given to patient:>>	
Referred to:	<<Referred to>>	
Preferred patient contact method and time:	<<Preferred patient contact method and time>>	

NB: If referring to Murray PHN  Mental Health Care Program  - PTS or MHCCC, 
Please call 1300 514 811 whilst the patient is still in the consultation so we can 
streamline the referral quickly.  Then please fax this GPMHTP & referral form to: 03 9376 0317

PATIENT CONSENT:

I, <<Patient Demographics:Full Name>> consent for this Care Plan to proceed and I agree to information about my mental health being shared between my GP and the mental health worker to whom I am referred, to assist in the management of my health care. To enable this referral to proceed, I also agree to information to be provided to the mental health intake line.

										
Signature (patient):				Date:  <<Miscellaneous:Date (short)>>
<<Patient Demographics:Full Name>>							

I  <<Doctor:Name>> 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.	

										              
GP Signature:			               	      Date:  <<Miscellaneous:Date (short)>>
<<Doctor:Name>>  

This document will be maintained in accordance with the relevant Privacy Legislation.