Patient Details
Re: <PtFullName>
DOB: <PtDoB>

PHN Mental Health Intake Stepped Care services 
(version 2.0 - January 2021)

For support completing this referral form: 
•	Refer to HealthPathways
•	Call PHN Mental Health Intake on 1300 747 724 
•	Email mentalhealthintake@ourphn.org.au 

For diagnostic and management advice: 
•	Call the GP Psychiatry Support Line on 1800 161 718

ONLY send referrals via Medical Objects 
MENTAL HEALTH CQ PHN 
(PC4558000B1)
OR
via fax to 1300 787 494

IMPORTANT REFERRAL INFORMATION  
<Fields with * denote mandatory and I understand the referral will not be accepted if left blank> Fields with * denote a mandatory field. I understand that referral will NOT be accepted if field is left blank. 

<I understand that Stepped Care is not a crisis service, Our operating hours are Monday to Friday 8.30am-4.30pm, excluding public holidays. Patients in crisis should be referred to the local Acute Care Team by calling 1300 MH CALL (1300 642 255), or if an emergency, dial 000.> I understand that Stepped Care Intake is NOT a crisis service. Our operating hours are Monday to Friday 8.30am-4.30pm, excluding public holidays. Patients in crisis should be referred to the local Acute Care Team by calling 1300 MH CALL (1300 642 255), or if an emergency, dial 000. 

<For referrals for psychological therapies - I understand this program is only for eligible patients meeting the 'underserviced' groups (refer healthpathways 'Stepped Care' program) , and that the PHN may suggest this referral is better suited to BetterAccess.> For referrals for psychology therapies - I understand that this program is only for eligible patients meeting the ‘underserviced’ groups (refer to HealthPathways ‘Stepped Care’ page), and that the PHN may suggest this referral is better suited to BetterAccess.

Referrer Details
Referrer name* | <DrName> | Date of referral* | <TodaysDate>
Referrer position/profession* | <Referrer position/profession> | Referrer provider number | <DrProviderNo>
Name of referring practice | <Practice> | Referrer phone* | <UsrPhone>
Referrer email | <PracEmail> | Referrer fax | <UsrFax>

Client Consent & Basic Client Demographics
Has consent been given for referral?* <Has consent been given for referral?*>
If under 18 mature minor, can referral be discussed with guardian?* <If <18, can referral be discussed with guardian?*>
Is it OK for the PHN to contact the client/guardian, if required? <Can PHN contact the client/guardian, if reqd?>

Client Name*: <PtFullName>
Date of Birth*: <PtDoB>	Gender: <PtSex>
Indigenous identity (tick relevant)* Torres Strait Islander <Torres Strait Islander> Aboriginal <Aboriginal>
Country of birth* <Country of birth> 
Preferred Language: <Preferred language>
Interpreter required: <Interpreter required>
Co-morbidities/medical history: <SelectedPMH>
Substance use: <Substance Use>

Other Client Demographics (Used to determine eligibility for psychological therapies)
NB – these fields are required to determine eligibility for psychological therapies

GP MH Treatment Plan* | <GP MH Treatment Plan*>
Employment | <Employment>
Source of income* | <Source of income*>
Homelessness* | <Homelessness*>
NDIS and support coordination* | <NDIS and support co-ordination*>

Financial disadvantage* (e.g. can they afford a gap payment at this time)

<Financial Disadvantage (ie can they afford a gap payment at this time)?*>

If applicable, provide concession card no. <PtPensionNo>

Rural / remote (MMM4-7)* (See search tool to check) | <Rural / remote (MMM4-7)*>
Culturally and Linguistically Diverse (CALD)* | <Culturally and Linguistically Diverse (CALD)*>
LGBTIQ+* | <LGBTIQ+*>
Perinatal depression* | <Perinatal depression*>
Domestic/family violence | <Domestic/family violence>
Private health insurance | <Private health insurance>
Has used Better Access in last 12 months | <Has used Better Access in last 12 months>

Client Contact Details
Address: <PtStreet> City: <PtCity> Postcode: <PtPostcode>
Client Contact:  Mobile: <PtPhoneMob>  Email: <PtEmail>
Guardian Contact  Mobile: <Guardian mobile number>  Email: <Guardian email>

Referral Information
What support do you believe this person requires?* 
<What support do you believe this person requires?*>

Reason for referral* 
<Reason for referral>

Risk Information

The below section is based on the Initial Assessment and Referral national guidance. <Please complete the Provisional Risk Assessment  below:>

It is a provisional assessment only and aims to inform the most appropriate response and/or referral. For more information on suicide risk assessment, refer to HealthPathways Suicide Prevention page.

Suicidality* <Suicidality*>
0 = No risk
1 = Low risk (e.g., no current suicidal ideation; some past ideation)
2 = Moderate risk (e.g., current suicidal ideation, without plan or intent)
3 = High risk (e.g., current ideation with intent; history of attempts; some protective factors)
4 = Extreme risk (e.g., current suicidal intention with plan and means to carry out)
Self-harm (non-suicidal self-injurious behaviour)* <Self-harm (non-suicidal self-injurious behaviour)*>
0 = No risk
1 = Low risk (e.g., risk of harm to self, or occasional self-harm recently)
2 = Moderate risk (e.g., frequent self-harm recently, non life-threatening harm to self)
3 = High risk (e.g., frequent self-harm recently, recent life-threatening harm to self)
4 = Extreme risk (e.g., repeated life-threatening self-harm, or imminent risk to self)
Risk of harm to others* <Risk of harm to others*>
0 = No risk
1 = Low risk (e.g., past behaviours that posed a risk to others)
2 = Moderate risk (e.g., recent behaviours that pose non-life-threatening risk to others)
3 = High risk (e.g., recent life-threatening risk to others)
4 = Extreme risk (e.g., recent behaviour that poses an imminent danger to others)

If moderate risk or greater in any category, please add comments* <If moderate risk or greater in any category, please add comments*>
Has a safety plan been completed with the client?  <Has a safety plan been completed for the client?>
Has the client ever been hospitalised due to their mental health? <Has the client ever been hospitalised due to their mental health?>
If yes, date of most recent admission <If yes, date of most recent admission>

Assessments
<ASSESSMENTS>
<K10+ Scale> | Kessler Psychological Distress Scale (K10+)
<K5 Scale> | Kessler 5 Psychological Distress Scale (K5 - for Aboriginal and Torres Strait Islander people)
<SIDAS Scale> | Suicidal Ideation Attributes Scale (SIDAS)
<DASS-21 Scale> | Depression, Anxiety and Stress Scale (DASS-21)
<Other> | Other – please specify  <If 'Other' - please specify>

GP Mental Health Treatment Plan

Please attach patient's Mental Health Treatment Plan. Please note that this is required for referral for Psychological Therapies (all patients) and Clinical Care Coordination (required for adult patients only; recommended for child and youth patients).