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

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:	
Patient Demographics.  Full Name	Outcome Tool Results:
K10/DASS (please circle)	
Outcome Tool Results	
Address:	Patient Demographics.  Full Address	Phone Number:	Patient Demographics.  Phone (Home)
Patient Demographics.  Phone (Mobile)	
DOB:	Patient Demographics.  DOB	Gender:	Patient Demographics.  Gender	
Referral Date:	Miscellaneous.  Date	Medicare No#	Patient Demographics.  Medicare Number	
Does the patient identify as Aboriginal or Torres Strait Islander?	ATSI Status	
Is the patient from a Culturally and Linguistically Diverse background?	CALD Background	
Does the patient have a My Health Record?	My Health Record
Patient Demographics.IHI Number	

Patient Demographics 
Has the patient ever received specialist mental health care? Mental Health Care 	
Language spoken at home:    Language spoken
How well does the patient speak English:   Speak English
Does the patient require an interpreter: Interpreter	
Does the patient live alone: Lives alone  if no, with whom___________________
Is the accommodation:  Accommodation	
Country of birth: Country of birth         Nationality:  Nationality	
Employment Status: Employment Status	
Pension or Health Card Status:  Pensions/HCC Status	
Marital Status:  Marital Status	
Does the patient have any dependents:  Dependents	
Psychosocial assessment: (e.g. childhood, substance abuse, relationship history, coping with previous stressors)	

Psychosocial assess	
 Eligibility Criteria for Primary Mental Health Care Services -  
Eligibility Criteria	
Mental Status Examination:	
Appearance and General Behaviour Appearance 	Mood (Depressed/Labile)  Mood 	
Thinking (Content/Rate/Disturbances) Thinking 	Affect (Flat/Blunted)  Affect 	
Perception (Hallucinations etc.) Perception 	Sleep (initial Insomnia/Early Morning Wakening) Sleep 	
Cognition (level of Consciousness/Delirium/Intelligence) Cognition 	Appetite (Disturbed Eating Patterns) Appetite 	
Attention/Concentration: Attention/Concerntat	Motivation/Energy : Motivation/Energy
     	
Memory (Short and Long Term) Memory 	Judgement (ability to make rational decisions) Judgement 	
Insight Insight 	Anxiety Symptoms (Physical & Emotional)  Anxiety Symptoms 	
Orientation (Time/Place/Person) Orientation 
	Speech (Volume/Rate/Content) Speech 	
Other Mental Health Professionals involved in patient care	
Name/Profession:	Contact number:	

GP Details
Name:	Treating Doctor.Name	Practice Name:	Practice.Name	
Address:	Practice.Address	Phone:	Practice.Phone	
Presenting Problem/ Provisional Diagnosis (must complete)
Number 1	Number 2	Number 3	
Presenting Problem 1	Presenting Problem 2	Presenting problem 3	
Risk Assessment (must complete)
Suicidal ideation:	Suicidal Ideation	Suicide intent	 Suicide Intent	
Current suicidal plan:	Current Suicidal 	Risk to others	Risk to others	
GUIDE TO ABOVE RISK ASSESSMENT OUTCOME: 
If YES to one or more of the above Risk Assessment questions please contact your local service provider.
If NO to the above Risk Assessment Clinical Triage will determine the service provider based on information supplied in this referral.	
Other Comments 

Medications:  Clinical Details.Medications - Current PRN

	Allergies: Clinical Details.Allergies	
Relevant physical and mental examination:  Relevant physical 

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. 	
Clinical Details.Family History
Clinical Details.Social History
Clinical Details.History List
Clinical Details.Problem List (Current)
Clinical Details.Todays Notes

Step 2: Mental Health Care Plan
Key family contact/support details/phone:	
Support
	
Emergency Care/relapse prevention:	
Emergency Care
	
Initial action plan:	
GOAL	TREATMENT	REFERRALS	
Initial action plan	Initial action plan	Initial action plan

	
Review date: (Add a recall in clinical software for 3-4 months after the Plan date)   	
Review date	
Copy of Mental Health Treatment Plan given to Patient: 	MH Treatment plan	
Patient Consent to release information (must complete)	
I, Patient Demographics.Full Name (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: Miscellaneous.Date
GP Signature____________________________            Date: Miscellaneous.Date
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