Adelaide Primary Mental Health Care Sevices (PMHCS)
Mental Health Treatment plan 
Item 2715/2717/2701/2700

FAX YOUR COMPLETED REFERRAL FORM TO THE PMHCS CENTRAL REFERRAL TEAM ON: 1300 580 249

Please note these details MUST be provided before the Mental Health Treatment Plan will be accepted by the PMHCS Central Referral Team for allocation to a service provider: Patient details, GP Details, Problem, diagnosis, Risk Assessment, Patient Consent and GP signature 

Step 1: Patient Assessment
Patient Details (must complete)
Name:	
<PtFullName>	Outcome Tool Results:
K10/DASS (please circle)	<Outcome Tool Results - K10/DASS>	
Address:	<PtAddress>	Phone Number:	<PtPhoneH> <PtPhoneMob>	
DOB:	<PtDoB>	Gender:	<PtSex>	
Referral Date:	<TodaysDate>	Medicare No#	<PtMCNo>	
Does the patient identify as Aboriginal or Torres Strait Islander?	     <Identify as Aboriginal or Torres Strait Islander>	
Is the patient from a Culturally and Linguistically Diverse background?	<Is the patient from a CALD background>	
Does the patient have a My Health Record?	<Does the patient have a My Health Record?>
<PtIHI>	

Patient Demographics 
Has the patient ever received specialist mental health care?  <Has the patient ever received specialist mental health care?>	
Language spoken at home:    <Language Spoken at home>
How well does the patient speak English:   <How well does the patient speak english ?>
Does the patient require an interpreter: <Does the patient require an interpreter>	
Does the patient live alone: <Does the patient live alone>  If no, with whom___________________
Is the accommodation:  <Is the accomodation>	
Country of birth: <Country of birth>          Nationality:  <Nationality>	
Employment Status:  <Employment Status>	
Pension or Health Card Status:  <Pension or Health Care Card Status>	
Marital Status:  <Marital Status>	
Does the patient have any dependents:  <Does the patient have any dependents>	
Psychosocial assessment: (e.g. childhood, substance abuse, relationship history, coping with previous stressors)	
<Psychosocial assessment:>
	
 Eligibility Criteria for Primary Mental Health Care Services -  
<Eligibility Criteria - Tick as many as applicable>

Mental Status Examination:	
Appearance and General Behaviour <Mental Status Examination - Appreance and General Behaviour>
 <Appreance and General Behaviour - Other - please specify>	Mood (Depressed/Labile)  <Mental Status Examination - Mood (Depressed/Labile)>
 <Mental Status Examination - Mood (Depressed/Labile)- Other - please specify>	
Thinking (Content/Rate/Disturbances) <Mental Status Examination -Thinking (Content/Rate/Disturban>
<Mental Status Examination -Thinking (Content/Rate/Disturban - Other - please specify>	Affect (Flat/Blunted)  <Mental Status Examination - Affect (Flat/Blunted)>
<Mental Status Examination - Affect (Flat/Blunted) - Other - please specify>	
Perception (Hallucinations etc.) <Mental Status Examination - Perception (Hallucinations etc.)>
<Mental Status Examination - Perception (Hallucinations etc.) - Other - please specify>	Sleep (initial Insomnia/Early Morning Wakening) <Mental Status Examination -Sleep(initial Insomnia/Early wake>
<Mental Status Examination -Sleep(initial Insomnia/Early wake - Other - please specify>	
Cognition (level of Consciousness/Delirium/Intelligence) - <Mental Status Examination - Cognition>
<Mental Status Examination - Cognition - Other - please specify>	Appetite (Disturbed Eating Patterns) <Mental Status Examination -Appetite(Disturbed Eating Pattern>
<Mental Status Examination -Appetite(Disturbed Eating Pattern - Other - please specify>	
Attention/Concerntation: <Mental Status Examination - Attention/Concerntation>
<Mental Status Examination - Attention/Concerntation - Other - please specify>	Motivation/Energy <Mental Status Examination - Motivation/Energy>
<Mental Status Examination - Motivation/Energy - Other - please specify>     	
Memory (Short and Long Term)  <Mental Status Examination - Memory (Short and Long Term)>  
<Mental Status Examination - Memory (Short and Long Term) Other - please specify>	Judgement (ability to make rational decisions) <Mental Status Examination - Judgement>
<Mental Status Examination - Judgement - Other - please specify>	
Insight <Mental Status Examination - Insight>
<Mental Status Examination - Insight - Other - please specify>	Anxiety Symptoms (Physical & Emotional)  <Mental Status Examination - Anxiety Symptoms>
<Mental Status Examination - Anxiety Symptoms - Other - please specify>	
Orientation (Time/Place/Person) <Mental Status Examination - Orientation (Time/Place/Person)>
<Mental Status Examination - Orientation (Time/Place/Person) - Other - please specify>	Speech (Volume/Rate/Content) <Mental Status Examination - Speech (Volume/Rate/Content)>
<Mental Status Examination - Speech (Volume/Rate/Content) - Other - please specify>	
Relevant physical and mental examination:  <Relevant physical and mental examination:>	
Other Mental Health Professionals involved in patient care	
Name/Profession:	Contact number:	

GP Details
Name:	<DrName>	Practice Name:	<Practice>	
Address:	<UsrAddress>	Phone:	<UsrPhone>	
Presenting Problem/ Provisional Diagnosis (must complete)
Number 1	Number 2	Number 3	
<Problem/diagnosis (must complete) Number 1>	<Problem/diagnosis (must complete) Number 2>	<Problem/diagnosis (must complete) Number 3>

Risk Assessment (must complete)
Suicidal ideation:	 <Risk Assessment (must complete) - Suicidal Ideation>	Suicide intent	 <Risk Assessment (must complete) - Suicide Intent>	
Current suicidal plan:	<Risk Assessment (must complete) - Current suicidal plan>	Risk to others	<Risk Assessment (must complete) - Risk to others>	
GUIDE TO ABOVE RISK ASSESMENT OUTCOME: 
If YES to one or more of the above Risk Assesment questions please contact your local service provider.
If NO to the above Risk Assesment Clinical Triage will determine the service provider based on information supplied in this referral.	
Other Comments 

Medications:  <SelectedRx>

  
	Allergies: <Reactions>	

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. 	
<FamilyHx>
<SocialHx>
<SelectedPMH>

	

Step 2: Mental Health Care Plan
Key family contact/support details/phone:	
  <Key family contact/support details/phone:>
	
Emergency Care/relapse prevention:	
<Emergency Care/relapse prevention>

	
Initial action plan:	
GOAL	TREATMENT	REFERRALS	
<Initial action plan - GOAL>	<Initial action plan - TREATMENT>	<Intial action plan: REFERRALS>

	
Review date: (Add a recall in clinical software for 3-4 months after the Plan date)   	<Review date - 3 -4 months after the PLAN date>	
Copy of Mental Health Treatment Plan given to Patient: 	<Copy of Mental Health Treatment Plan given to Patient>	
Patient Consent to release information (must complete)	
I, <PtFullName> (patient name-please print clearly) understand that this MHTP 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 APHN 
Therefore, in complying with the principles governing provision of this service we seek your consent. 
Patient signature________________________             Date: <TodaysDate>
GP Signature____________________________            Date: <TodaysDate>
For patients under 16 years:
Carer name:_____________________________           Carer signature___________________

PLEASE FAX YOUR COMPLETED REFERRAL FORM TO THE PMHCS CENTRAL REFERRAL TEAM ON: 1300 580 249