Referral Data Form

Referring General Practitioner: GP Details GP Address Patient Information: Name Gender Phone # Language English Le#el Referral Code: __________ Telephone Fax DOB: ____/____/______ Address Postcode Medicare # _______________________

M F Other_______ English onl $er %ell

A'original or Torres (trait )slander Client Eligibility:

services elsewhere

Not at all No +n,no%n A'original Torres (trait )slander Health Care Card/Centrelink Concession/ Pensioner Cannot afford

Other! please speci" &ell Not &ell *es *es

Referral Information: )s this an existing re"erral-

*es No . )" *es! please pro#ide existing re"erral code _________

Pre"erred Pro#ider /)nc0 Gender12_____________________________

ATAPS 3e"erral t pe

General 4hildren /5.66 rs1 (uicide Pre#ention Perinatal Depression A'original 8 Torres (trait )slander

7omelessness Forced Adoption

Partners in Recover Program Better Access Other! please speci" 2 ________________________________________________

Li#es alone Education

*es Tertiar

No *ear 69

Prior mental health care

*es

No Primar
or 'elo%

*ear 66

*ears 65.:

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

F6 Alcohol and Drug +se Disorders F9 Ps chotic Disorders F< Depression F= Anxiet Disorders F> +nexplained somatic disorders +n,no%n No "ormal diagnosis /(P( onl 1 Other2 ______________________________
'$% Score2__________ DASS ($ or )( !circle&:_________ Ot*er !test "sed + score&:_____________ Strategies Referred for ; Please tic, all that appl

Diagnostic Assessment Ps cho.education )nterpersonal Therap ?eha#ioural )nter#ention /4?T1 3elaxation (trategies /4?T1 (,ills Training /4?T1 4ogniti#e )nter#ention /4?T1 Famil ?ased /,ids onl 1 Parent 8 4hild /,ids onl Other 4?T inter#ention2 _________________________
C"rrent Ps c*otro,ic -edication ; Please tic, all that appl

None ?en@odia@epines 8 Anxiol Phenothia@ines 8 TranAuilisers

C PATI./T CO/S./T:!Patient to com,lete&
Patient &/or Patients parent/carer has agreed to GP mental Health Treatment Plan

tics

A copy of this completed form and a copy of the Mental Health reatment Plan !MH P" m#st be fa$ed or delivered to the nominated service and/or to the patient%

Antidepressants Mood (ta'ilisers Other__________________________

(ignature2_________________________________

Referral Data Form

Name2_________________________ Date2 __________

GP CO/S./T: /GP to complete1

(ignature2_______________________ Date2 __________