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	
Full Name	<<Patient Demographics:Full Name>>		    	
Date of Birth	<<Patient Demographics:DOB>>	Email	<<Patient Demographics:E-mail>>	
Street Address	<<Patient Demographics:Address Line 1>>	Gender	 <<Patient Demographics:Gender>>	
Suburb		<<Patient Demographics:Address Postal City>>	Postcode	<<Patient Demographics:Address Preferred Postcode>>	Mobile No. 	<<Patient Demographics:Phone (Mobile)>>	
Home Phone No. 	<<Patient Demographics:Phone (Home)>>		
Aborignal and/or Torres Strait Islander	<<Patient Demographics:Ethnicity>>			
Country of birth		<<Patient Demographics:Country of Birth>>	Main language spoken at home?
Interpreter Required	<<Patient Demographics:Language Preferred>>
<<Interpreter Required>>	
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
<<Anxiety Disorders>> 
Affective/ Mood Disorders
<<Affective/ Mood Disorders>>
Psychotic Disorders
<<Psychotic Disorders>>
Childhood/ Adolescence
<<Childhood /Adolescence>>
Substance use disorders
<<Substance Use Disorders>>
Other
<<Other - please state>>

Severity 	<<Severity>>	

Psychotropic medication	<<Clinical Details:Medication List>>	
Outcome tool score
(attach form)	<<Outcome Tool Used>>
<<Score>>	
Previous Mental Health history or treatment attached		Mental Health Treatment plan attached
<<Previous Mental Health history or treatment attache>>	<<Mental Health Treatment plan attached>>

Physical health conditions to note:
<<Clinical Details:History List>>
PRIORTY GROUP	
Underserviced group 		
<<Underserviced group>>

SERVICES REQUESTED	
 Referred for which service 		
<<Referred for which service>>

Preferred Provider: <<Preferred Provider>> 		No Preference: <<If no preferred provider leave blank>>

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	<<Emergency Contact>>	Daytime Phone #	<<Emergency contact phone number>>	
Relationship	<<Relationship to emergency contact>>	Email	<<Emergency contact email>>	

REFERRER DETAILS	Date of Referral	  <<Miscellaneous:Date>>	
First Name	<<Doctor:Name>>			
Organisation/Practice	<<Practice:Name>>	
Street Address	<<Doctor:Address Line 1>>	
Suburb	<<Doctor:City>>	Postcode	<<Doctor:Postcode>>	State	<<Doctor:State>>	
Provider No.	<<Doctor:Provider Number>>	Fax No. 	<<Doctor:Fax>>	
Daytime Phone No.	<<Doctor:Phone>>	Email	<<Doctor:E-mail>>	
Consent	Patient or parent/ guardian for a child      <<Consent - 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 >>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 s>> MHTP & Outcome measure is attached (ONLY for short term psychological therapies)

 
Send completed forms via Secure Fax (02) 8072 6899