<AdrDetails>	                     <TodaysDate>

RE: <PtFullName>

Thank you for seeing <PtFirstName>, who is currently a patient of mine.
<PtFirstName> is currently experiencing: <Current Presentation>

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

PATIENT DETAILS:	
Patient Name 	<PtFullName>	
Assessment Date 	<DayAndDate>	
DOB 	<PtDoB>	
Gender 	<PtSex>  <Does not identify a gender>	
Culture & language 	<Preferred Language> 
<Language Spoken>
<Proficiency in English>	
GP 	<DrDetails>	
Significant support person	<Indentified parent/support>	
Medicare card Number 	<PtMCNo>	
Health care card number	<PtPensionNo>	

PATIENT HISTORY - GENERAL	
Clinical History	
<PMHAll>	
Medications	
<PastRx>	
Allergies	
<Reactions> 	
Family History	
<FamilyHx> 	
Significant cultural factors	
<PtEthnicity> 	

PSYCHO-SOCIAL ASSESSMENT - HEADSS	
H – Home situation: 	
<Home (Consider - living arrangments, risks, abuse)> 	
E – Education, Employment, Eating, Exercise:	
 <Education, Employment, Eating, Exercise>	
A – Activities, Hobbies & Peer Relationships:	
<Activities, Hobbies & Peer Relationships>	
D – Drug Use:	
 <Drug Use/ Alcohol/ Cigerettes/ Cafeine Drinks>	
S – Sexual Activity & Sexuality	
<Sexual Activity & Sexuality>	
S – Suicide, Depression & Mental Health, Safety/Risk	
Refer to mental status and risk assessment below:	
K10+ outcome tool & result (if appropriate):	<K10+ Scores>	
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/ Intelligence)>	Appetite  	<Appetite (Disturbed Eating Patterns)>	
Attention / Concentration	<Attention and Concentration>	Motivation & energy	<Motivation and Energy>	
Memory	<Memory (Short & Long Term)>	Judgment	 <Judgement (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:	<UsrPhone>	
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 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, <PtFullName> 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:  <TodaysDate>
<PtFullName>							

I, <DrName> 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:  <TodaysDate>
<DrName>  

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