REFERRAL FORM
CRITERIA
For referral to short-term psychological therapies, please confirm the following (must check both items to be eligible).
<Patient is unable to access Medicare rebated (Better Access) psychological services OR cannot afford the gap payment under Medicare>Patient is unable to access Medicare rebated (Better Access) psychological services OR cannot afford the gap payment under Medicare
<Mental Health Treatment Plan and outcome measure attached>Mental Health Treatment Plan and outcome measure attached

PATIENT DETAILS	
First Name	<PtFirstName>	Last Name	    <PtSurname>	
Date of Birth	<PtDoB>	Email	<PtEmail>	
Street Address	<PtStreet>	Gender	 <PtSex>	
Suburb		<PtCity>	Postcode	<PtPostcode>	Mobile No. 	<PtPhoneMob>	
Home Phone No. 	<PtPhoneH>		
Aborignal and/or Torres Strait Islander	<Aboriginal> Aboriginal
<Torres Strait Islander> Torres Strait Islander
<Aboriginal and Torres Strait Islander> Aboriginal and Torres Strait Islander
			
Country of birth		<PtEthnicity>	Main language spoken at home?	<Language spoken at home>	
Spoken English Level	<Spoken English level>	
Employment Status	<Employment status>	
NDIS participant	<NDIS participant>	
Healthcare card	<Healthcare card>	
MENTAL HEALTH PRESENTATIONS	
Suicide prevention referral	<Suicide prevention referral>	
If person is at immediate risk (intent or plan), contact the Mental Health Access line: 1800 055 511

Presenting issues: <Presenting issues>           
See Mental Health Treatment Plan <See Mental Health Treatment Plan>

PRINCIPAL DIAGNOSIS	
Anxiety Disorders	<Stress related> Stress related
<Panic disorder>Panic disorder
<Social Phobia> Social Phobia
<Generalised anxiety (GAD)> Generalised anxiety (GAD)
<Obsessive copmulsive disorder>Obsessive copmulsive disorder
<Post traumatic stress disorder> Post traumatic stress disorder
	
Affective/ Mood Disorders	<Major depression> Major depression
<Adjustment disorder> Adjustment disorder
<Depressive symptoms> Depressive symptoms
<Bipolar disorder> Bipolar disorder	
Psychotic Disorders	<Schizophrenia> Schizophrenia
<Eating disorder> Eating disorder
<Personality disorder> Personality disorder	
Childhood/ Adolescence	<Adjustment disorder> Adjustment disorder
<Oppositional defiant disorder> Oppositional defiant disorder
<Conduct disorder> Conduct disorder 
<ADHD-Attention dificit hyperactivity disorder> ADHD-Attention dificit hyperactivity disorder	
Substance use disorders	<Alcohol dependance> Alcohol dependance
<Other drug dependence>Other drug dependence	
Other	<Other mental disorder - please state>	

Severity 	<Severity>	

Psychotropic medication	<SelectedRx>	
Outcome tool score
(attach form)	<Outcome score tool used> 
<Score>	
Previous Mental Health history or treatment:				Mental Health Treatment plan attached
<Previous mental health history or treatment>				<Mental Health Treatment plan attached>

Physical health conditions to note:
<SelectedPMH>

PRIORTY GROUP	
Underserviced group	<Young Person (12-25yrs)> Young Person (12-25yrs)
<Child (0-11yrs)>  Child (0-11yrs)
<Aboriginal and/or Torres Strait Islander> Aboriginal and/ or Torres Strait Islander
<Carer> Carer
<Culterally and linguistically diverse> Culterally and linguistically diverse
<Peri-natal> Peri-natal
<Lesbian, gay, bisexual, trans, and/or intersex> Lesbian, gay, bi-sexual, trans, and/or intersex

SERVICES REQUESTED	
Referred for which service	<Short-term individual psychological therapies> Short-term individual psychological therapies
<Short-term group psychological therapies> Short-term group psychological therapies
<Low intensity psychological interventions> Low intensity psychological interventions
<Support service following a suicide attempt> Support service following a suicide attempt
<Clinical care coordination for Severe and Complex Mental Illness> Clinical care coodrdiantion for severe and complex mental illness
<Alcohol and drugs counselling> Alcohol and drugs counselling
<Eating disorder services> Eating disorder services
<Indigenous specific services> Indigenous specific services
<Other>  Other	
Preferred Provider: <Preferred provider (if any)>   		No Preference: <No preference>

ADDITIONAL INFORMATION	
<Additional information> 

EMERGENCY CONTACT INFORMATION	
Who does the patient nominate to be a contact to communicate with to support the patient (if needed)?	
Name	<NOKName>	Daytime Phone #	<NOKContact>	
Relationship	<NOKRelation>	Email		

REFERRER DETAILS	Date of Referral	  <TodaysDate>	
First Name	<DrFirstName>	Last Name	<DrSurname>	
Referrer Type	 <Referrer Type> 
Other: <Other - please state>                   	
Organisation/Practice	<Practice>	
Street Address	<DrStreet>	
Suburb	<DrCity>	Postcode	<DrPostcode>	State	<DrState>	
Provider No.	<DrProviderNo>	Fax No. 	<DrFax>	
Daytime Phone No.	<DrPhone>	Email	<DrEmail>	
Consent	Patient or parent/ guardian for a child      <Patient or parent/ guardian for a child>	
Patient has been informed of the role and serices that SNPHN provides and underststands that the information provided in this referral is required to determine eleigibility for services. Patient gives consent for services to be provided by suitable SNPHN-commissioned providers, as requested on this referral. Patient gives permission for the exchange of this information between GP, SNPHN Mental Health Triage staff, Commissioned Service Provider, allocated health professional and other agencies for the purpose of coordination of care.
REFERRALS FOR SHORT-TERM PSYCHOLOGICAL THERAPIES ONLY
<Patient may be referred under the Better Access to Mental Health Services, if practitioner will bulk bill AND I have lodged an MBS item 2700/2701/2715/2717> Patient may be referred under the Better Access to Mental Health Services, if practitioner will bulk bill AND I have lodged an MBS item 2700/2701/2715/2717

GPs are asked to please use items 36 or 44 for children

PLEASE ENSURE THE FOLLOWING IS COMPLETE BEFORE SENDING TO SNPHN:
	<	Patient contact information including phone number> Patient contact information including phone number
<Patient has consented to referral> Patient has consented to referral    
<MHTP & Outcome measure is attached (ONLY for short term psychological therapies)> MHTP & Outcome measure is attached (ONLY for short term psychological therapies)

 
Send completed forms via Secure Fax (02) 8072 6899