8/12/2019 2013_11_22 Grampians Medicare Local - Mental_Health_ Referral_Form

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Referral Data Form

Referring General Practitioner: Referral Code: __________

GP Details Telephone

GP Address Fax

Patient Information: DOB: ____/____/______

Name Address

Gender M F Other_______ Postcode

Phone # Medicare #

Language English onl Other! please speci"_______________________

English Leel $er %ell &ell Not &ell Not at all

A'original or Torres (trait )slander *es *es No +n,no%nA'original Torres (trait )slander

Referral Information:

)s this an existing re"erral-*es No . )" *es! please proide existing re"erral code _________

Pre"erred Proider /)nc0 Gender12_____________________________

3e"erral tpe

ATAPSGeneral 4hildren /5.66rs1 7omelessness(uicide Preention Perinatal Depression Forced AdoptionA'original 8 Torres (trait )slander

Partners in Recover Program Better Access

Other! please speci"2 ________________________________________________

Lies alone *es No Prior mental healthcare

*es No

Education Tertiar *ear 69 *ear 66 *ears 65.: Primar or 'elo%

Primar Diagnosis !"sing ICD#$%&; Please tic, all that appl

F6 Alcohol and Drug +seDisorders F9 Pschotic Disorders F< DepressionF= Anxiet Disorders F> +nexplained somatic disorders +n,no%n

No "ormal diagnosis /(P( onl1 Other2 ______________________________

'$% Score2__________ DASS ($ or )( !circle&:_________ Ot*er !test "sed + score&:_____________

Strategies Referred for; Please tic, all that appl

Diagnostic Assessment Pscho.education )nterpersonal Therap?ehaioural )nterention /4?T1 3elaxation (trategies /4?T1 (,ills Training /4?T1

4ognitie )nterention /4?T1 Famil ?ased /,ids onl1 Parent 8 4hild /,ids onl1

Other 4?T interention2_________________________

C"rrent Psc*otro,ic -edication; Please tic, all that appl

None ?en@odia@epines 8 Anxioltics Antidepressants Mood (ta'ilisers

Phenothia@ines 8 Tranuilisers Other__________________________

PATI.T COS.T:!Patient to com,lete&Patient &/or Patients parent/carer has agreed toGP mental Health Treatment Plan

(ignature2_________________________________

Client Eligibility: Health Care Card/Centrelink Concession/ Pensioner Cannot afford

services elsewhere

A copy of this completed form and a copy of the Mental Health reatment Plan !MHP" m#st be fa$ed or

delivered to the nominated service and/or to the patient%C

8/12/2019 2013_11_22 Grampians Medicare Local - Mental_Health_ Referral_Form

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Referral Data Form

Name2_________________________ Date2 __________

GP COS.T:/GP to complete1 (ignature2_______________________ Date2 __________