Adelaide Primary Mental Health Care Services 
Mental Health Treatment Plan 
Item 2715/2717/2701/2700

Please send your completed referral to the Central Referral Unit Team via secure messaging:

HealthLink EDI: adphncru

Argus/ReferralNet ID: CRU

Step 1 - Patient Assessment

Patient Name: | Patient Demographics.Full Name | Outcome Tool K10 | Outcome Tool K10/DAS
DOB: | Patient Demographics.DOB | Gender: | Patient Demographics.Gender | Date: | Miscellaneous.Date

Address

Patient Demographics.Address
Suburb: Patient Demographics.Suburb  Patient Demographics.Postcode

Phone

Patient Demographics.Phone (Mobile)

Medicare #

Patient Demographics.Medicare Number

Does the patient identify as Aboriginal or Torres Strait Islander? | Does the patient ide | Does the patient identify as Culturally and Linguistically Diverse? | Does the patient ide

GP Name | Treating Doctor.Name | Provider Number | Treating Doctor.Provider Number
Practice | Practice.Name | Phone | Practice.Phone

Mental Health History/Treatment

Has the person ever recieved specialist mental health care?  Has the person ever 
Language spoken at home:  Language  
How well does the person speak English: How well does the pe
Does the patient require an interpreter? Does the patient req
   Does the person live alone: Does the person live
Is the accommodation: is the acc
Country of Birth: Country
Nationality: Nationality
Employment Status: Employment Status
Pension or Health Care Card Status: Pension or
Marital Status: Martial Status
Does the patient have any dependents: Does the patient hav
Highest education level completed:

Psychosocial Assessment (e.g childhood, substance abuse, relationship history, coping with previous stressors)
Psychosocial Assessm

Eligibility

Eligibility Criteria for Primary Mental Health Care Services: Eligibility
Does the patient have the ability to pay a gap fee? Does the patient hav

Mental Status Examination |

Appearance and General Behaviour
Normal / Other  Other

Mood (Depressed/Labile)
Normal / Other  Other

Thinking (Content/Rate/Disturbances)
Normal / Other  Other

Affect  (Flat/blunted)
Normal / Other  Other

Perception (Hallucinations etc.)
Normal / Other  Other

Sleep  (Initial Insomnia/Early Morning Wakening)
Normal / Other  Other

Cognition (Level of Consciousness/Delirium/Intelligence)
Normal / Other  Other

Appetite  (Disturbed Eating Patterns)
Normal / Other  Other

Attention/Concentration
Normal / Other  Other

Motivation/Energy 
Normal / Other  Other

Memory  (Short and Long Term)
Normal / Other  Other

Judgement  (Ability to make rational decisions)
Normal / Other  Other

Insight
Normal / Other  Other

Anxiety Symptoms  (Physical & Emotional)
Normal / Other  Other

Orientation (Time/Place/Person)
Normal / Other  Other

Speech  (Volume/Rate/Content)
Normal / Other  Other

Risk Assessment
Suicidal Ideation | Suicidal Ideation | Suicidal Intent | Suicidal Intent
Current Plan | Current suicide plan | Risk to Others | Risk to others

GUIDE TO RISK ASSESSMENT OUTCOME:
If YES to one or more of the above Risk Assessment questions, please contact your local health service provider.

If NO to the above Risk Assessment, Clinic Triage will determine the service provider based on information in this referral.

Other comments: Other comments

Medications
Clinical Details.Medication List

Allergies
Clinical Details.Allergies

Patient History (Include relevant biological, psychological and social history including any family history of mental disorders and any relevant substance abuse or physical health problems)

Family History: Clinical Details.Family History

Social History: Clinical Details.Social History

Past History: Clinical Details.Past History

Other Mental Health Professionals Involved in Patient Care
Name/Profession:

Contact Number

Others Involved | Contact Number
Others Involved | Contact Number
Others Involved | Contact Number

Step 2 - Mental Health Care Plan

Problem/Diagnosis | Goal (eg reduce symptoms, improve functioning) | Action/Task (eg psychological or pharmacological treatment, referral, engagement of family and other supports)
Number 1: | |
1 Problem Diagnosis | Goal | Action Task
Number 2: | |
2 Problem Diagnosis | Goal | Action Task
Number 3: | |
3 Problem Diagnosis | Goal | Action Task

Emergency Care/Relapse Prevention | Emergency

Patient Education given: | Patient Education | Key family contact/support details/phone:
Copy of MH Plan given to patient: | Copy of MH Plan | Key family contact

Review Date: 
(Add a Recall for 1-6 months after the Plan date)

Review Date:

Record of Patient Consent

I Patient Demographics.Full Name understand that this Mental Health Treatment Plan is being used as a referral for the provision of mental health services. This process involves an assessment and the development of a plan for treatment. I agree to be part of the process with the knowledge that:
•	 My medical history will be shared with the GP and Clinician of the service chosen/and personnel of the chosen service where relevant;
•	 The information collected is private and will be kept confidential unless agreed upon by all parties to be shared;
•	 My GP has explained to me the reasons for seeking counselling/therapeutic input;
•	 No Medico Legal Reports will be provided;
•	I understand that my treatment will be monitored and communicated between my treatment team. 
•	All personal information gathered will remain confidential and secure with my treating team and within the clinical management system hosted by the funding body Adelaide PHN. 
Therefore, in complying with the principles governing provision of this service we seek your consent.

Record of Patient Consent

Has the patient read and consented to the above and  the Mental Health Treatment Plan referral and sharing of clinical information to the treating GP/ Clinician? Has the patient read
Date: Miscellaneous.Date

I,  Treating 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? I,  Treating Doctor.
Date: Miscellaneous.Date

For patients under 16 years:
Carer name: Consent under 16
Carer has provided consent: Consent under 16

Miscellaneous.Date | Name:  Patient Demographics.Full Name | DOB:  Patient Demographics.DOB | Page