Author: Julie O'Dea

PHN Mental Health Intake
Wide Bay

For further information on Stepped Care services, see HealthPathways.
For any questions, please call PHN Mental Health Intake on 1300  747  724  or email on mentalhealthintake@ourphn.org.au 

Send via Medical Objects to: 
PHN MENTAL HEALTH INTAKE WIDE BAY (PW45580006G)

Alternatively fax to: 1300 787 494

Referrer Details
Referrer Name: | | Date of Referral: |
Referrer Position/Profession: | GP | Referrer Provider Number: |
Name of referring practice: | | Referrer phone: |
Referrer Address: |
Client Information
Has client given consent for referral?
Client Name: |
DOB: | | Age: | | Sex: |
Ethnicity: | | Preferred Language: | | Interpreter required? |
Address: | | | |
| Suburb: | | Postcode: |
Client Contact Details | Mobile: |
| Home: |
| Work: |
| Email: |
Medicare No. | | DVA number: |
Health Care Card No. | | Private Health No. |
Marital Status: |
Medication: |
Allergies: |
Risk Information

Current suicidal ideation? 
Past suicide attempt?  
In the last 7 days?

Self- harm? 
Mental health hospital admission in the last 12 months? 
Risk of harm to others?

Demographic Information
Rural and Remote resident | | Culturally and Linguistically Diverse background |
Aboriginal and/or Torres Strait Islander | | LGBTIQ community member |
Female with Perinatal depression | | Financially disadvantaged (e.g. concession card holder) |
Affected by Domestic Violence | | Homeless (e.g. sleeping rough or couch surfing) |
NDIS participant | | DVA card holder |
Private health insurance | | To your knowledge, has the patient seen a psychologist this calendar year under Better Access? |
Referral Information
Which stream of support do you believe this person will be eligible for?
Reason for referral and mental health history:
Assessments

Please indicate the score of any assessments undertaken: 
Kessler Psychological Distress Scale (K10+) 
Kessler 5 Psychological Distress Scale (K5 - for Aboriginal and Torres Strait Islander people) 
Short Form Survey (SF-12) 
Health of the Nation Outcome Scale (HoNOS) 
Patient Health Questionnaire (PHQ-9) 
General Anxiety Disorder-7 (GAD-7) 
Suicidal Ideation Attributes Scale (SIDAS) 
Strengths and Difficulties Questionnaire (SDQ) 
Other

GP Mental Health Treatment Plan
Please attach, or copy and paste below, patient's Mental Health Treatment Plan (if applicable)