GP MENTAL HEALTH TREATMENT PLAN – VERSION FOR CHILDREN	
Notes: This form is designed for use with the following MBS items. Users should be familiar with the most recent item definitions and requirements.
MBS ITEM NUMBER: 	
	
2700	
	
2701	
	
2715	
	
2717	

Major headings are bold; prompts to consider lower case. Response fields can be expanded as required. Underlined items of either type are mandatory for compliance with Medicare requirements.
This document is not a referral letter. A referral letter must be sent to any additional providers involved in this mental health treatment plan.	
CONTACT AND DEMOGRAPHIC DETAILS	
GP name	<<Doctor:Name>>	GP phone	<<Doctor:Phone>>	
GP practice name	<<Practice:Name>>	GP fax	<<Doctor:Fax>>	
GP address	<<Doctor:Address>>, 
<<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>	Provider number	<<Doctor:Provider Number>>	
Relationship	This person has been my patient since	

and/or	

This person has been a patient at this practice since	

	
Was patient involved in discussion with GP about treatment plan?		
Yes	
	
No	

Was parent/guardian involved in discussion with GP about patient’s 
treatment plan?		
Yes	
	
No	

Was the parent considered for a mental health treatment plan?		
Yes	
	
No	

Patient surname	<<Patient Demographics:Surname>>	Date of  birth 	<<Patient Demographics:DOB>>	
Patient first name(s)	<<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>	Preferred name	<<Patient Demographics:Greeting>>	
Gender	<<Patient Demographics:Gender>>	
Patient address	<<Patient Demographics:Address>>, <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	
Patient phone	Preferred number:	
<<Patient Demographics:Phone (Mobile)>>	

Can leave message?   	
	
Yes	
	
No	

	Alternative number:	
<<Patient Demographics:Phone (Home)>>	

Can leave message?   	
	
Yes	
	
No	

Medicare No.	<<Patient Demographics:Medicare Number>>	Healthcare Card No.	<<Patient Demographics:Pension Number>>	
Parent/guardian details  	Has patient consented for this Treatment Plan to be released to parents/guardians?	
First parent/guardian:	

<<Head of Family:Full Name>>	

	Relationship:	

	Phone number 1:	

Phone number 2:	

		
	
Yes	

With the following restrictions:	

		
	
No	

	
Second parent/guardian:	

	Relationship:	

	Phone number 1:	

Phone number 2:	

		
	
Yes	

With the following restrictions:	

		
	
No	

	

Emergency contact person details 	Patient/parent/guardian consent for healthcare team to contact emergency contacts?	
First contact:	

<<Head of Family:Full Name>>	

	Relationship:	

	Phone number 1:	

Phone number 2:	

		
	
Yes	

		
	
No	

	
Second contact:	

	Relationship:	

	Phone number 1:	

Phone number 2:	

		
	
Yes	

		
	
No	

	
Schooling (if applicable)	
Current school level		Name of school/pre-school		
Salient school factors
Consider:
•	Prior disruption to schooling
•	Current frequency of school attendance
•	Ability to start and finish homework
•	Peer relationships
•	Bullying
•	Traumatic school community events		
Patient/guardian consent to discuss GPMHTP with the following members of school community:	
	Role	Name(s)	Phone	
	
Yes	

	Principal			
	
Yes	

	Assistant Principal(s)			
	
Yes	

	Teacher(s)			
	
Yes	

	School Counsellor(s)			
	
Yes	

	Other			
SALIENT COMMUNICATION AND CULTURAL FACTORS	
Language spoken at home	<<Patient Demographics:Language Spoken>>	
Interpreter required	<<Patient Demographics:Requires Interpreter>>	
Country of birth	<<Patient Demographics:Country of Birth>>	
Other communication issues		
Other cultural issues		

PATIENT ASSESSMENT – MENTAL HEALTH	
Reasons for presenting
Consider:
•	What are the patient’s current mental health issues?
•	Behavioural issues
•	Requests and hopes		
History of current episode
Consider:
•	Symptom onset, duration, intensity, time course		
Implications of symptoms on child’s daily activities		
Patient history
Consider:		
•	Mental health history 		
•	Salient social history		
•	Salient medical/biological history 
•	♀ - menarche, menstruation, pregnancy, menopause		
•	Salient developmental issues		
Family history of mental illness
Consider:
•	Family history of suicidal behaviour
•	Genogram		
Current domestic and social circumstances
Consider:
•	Living arrangements
•	Siblings
•	Custodial arrangements
•	Social relationships
•	Engagement with peers		
Salient substance use issues
Consider:
•	Nicotine use
•	Alcohol use
•	Illicit substances
•	Is patient willing to address the issues?		
Current medications
Consider:
•	Dosage, date of commencement, date of change in dosage
•	Reason for the prescription 
•	Are there other practitioners involved in the prescription of medication?
•	Are there issues with compliance or misuse?		
History of medication and other treatments for mental illness
Consider:
•	School counselling and other school interventions
•	Past referrals
•	Effectiveness of previous treatments
•	Side-effects and complications associated with previous treatments
•	Patient’s preference for medications		
Allergies	<<Clinical Details:Allergies/Adverse Reactions>>	
Relevant physical examination and other investigations		
Results of relevant previous psychological and developmental testing		
Other care plan
e.g.  GP Management Plans and Team Care Arrangements; 
Wellness Recovery Action Plan		
Yes, specify:	

	

No	

Comments on Current Mental State Examination	
Consider:
•	Appearance, cognition, thought process, thought content, attention, memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation.		
Risk assessment
If high level of risk indicated, document actions taken in Treatment Plan below 
Consider:
•	Does the patient have a timeline for acting on a plan?
•	How bad is the pain/distress experienced?
•	Is it interminable, inescapable, intolerable?		
Ideation/ thoughts	
Intent	
Plan	

Suicide	

	

Self harm	

	

Harm to others	

	

Comments or details of any identified risks	

	
Assessment/outcome tool used, except where clinically inappropriate.
•	e.g., Strengths and Difficulties Questionnaire
•	Note: K-10 is not validated for minors		
Date of assessment		
Results		

Copy of completed tool provided to referred practitioner	

Provisional diagnosis of mental health disorder
Consider conditions specified in the ICPC, including:
•	Anxiety co-morbid with Autism
•	ADD/ADHD
•	Conduct disorder
•	Oppositional defiant disorder
•	Mood disorder
•	Separation anxiety
•	Phobias
•	Elective mutism
•	Reactive attachment disorder
•	Nonorganic enuresis and encopresis
•	Eating disorder
•	Adjustment disorder (e.g. grief/loss/ parental separation/trauma/medical condition)
•	Depression
•	Anxiety
•	Unexplained somatic disorder
•	Mental disorder not otherwise specified		
Case formulation
Consider:
•	Predisposing factors
•	Precipitating factors
•	Perpetuating factors
•	Protective factors		
Other relevant information from carer/informants
Consider:
•	Specific concerns of carer/family
•	Impact on carer/family
•	Contextual information from members of patient’s community
•	Other content from individuals other than the patient		
Any other comments		

PLAN	
Actions	
Identified issues/problems
Consider:
•	As presented by patient
•	Developed during consultation
•	Formulated by GP	Issue 1:	Issue 2:	Issue 3:	
Goals
Consider:
•	Goals made in collaboration with patient
•	What does the patient want to see as an outcome from this plan?
•	Behavioural or symptomatic goals
•	Wellbeing, function, occupation, relationships
•	Any reference to special outcome measures
•	Time frame				
Treatments & interventions
Consider:
•	psychological interventions
•	face to face
•	internet based
Program
•	The Brave Program (anxiety only)
Websites
•	Reach Out
•	BITE BACK
•	Eheadspace
Mobile Applications
•	Smiling Mind
•	Mind the Bump
•	Worry Time
•	The Desk
•	pharmacological interventions
•	Key actions to be taken by patient and by guardians
•	Support services to achieve patient goals
•	Parent Management Training
•	Role of GP
•	Psycho-education
•	Time frame				
Referrals
Consider:
•	Practitioner, service or agency—referred to whom and what for
•	Specific referral request
•	referral to internet mental health programs for education and/or specific
psychotherapy 
Program
•	The Brave Program (anxiety only)
Websites
•	Reach Out
•	BITE BACK
•	Eheadspace
Mobile Applications
•	Smiling Mind
•	Mind the Bump
•	Worry Time
•	The Desk
•	Opinion, planning, treatment
•	Case conferences
•	Time frame				
Any role of carer/support person(s)
Consider:
•	Identified role or task(s), e.g. monitoring, intervention, support
•	Discussed, agreed, negotiated with carer?
•	Any necessary supports for carer
•	Time frame				

Intervention/relapse prevention plan (if appropriate at this stage)
Consider:
•	Identify warning signs from past experiences
•	Note arrangements to intervene in case of relapse or crisis
•	Other support services currently in place
•	Note any past effective strategies		
Psycho-education provided if not already addressed in “treatments and interventions” above?		
Yes	
	
No	

Plan added to the patient’s records?		
Yes	
	
No	

  

Other healthcare providers and service providers involved in patient’s care
(e.g. psychologist, psychiatrist, social worker, occupational therapist, other GPs, other medical specialists, case worker, community mental health services)	
Role	Name	Address	Phone	

				

COMPLETING THE PLAN	
On completion of the plan, the GP may record (tick boxes below) that s/he has:	Date plan completed	
	
discussed the assessment with the patient	

	

discussed all aspects of the plan and the agreed date for review	

	

offered a copy of the plan to the patient and/or their carer (if agreed by patient)	

	

	

	

RECORD OF PATIENT CONSENT	
I, <<Patient Demographics:Full Name>> (name of patient), agree to information about my health being recorded in my medical file and being shared between the General Practitioner and other health care providers involved in my care, as nominated above, to assist in the management of my health care. I understand that I must inform my GP if I wish to change the nominated people involved in my care.  
I understand that as part of my care under this Mental Health Treatment plan, I should attend the General Practitioner for a review appointment at least 4 weeks after but within 6 months after the plan has been developed.
I consent to the release of the following information to the following carer/support and emergency contact persons:	
Name	Assessment	Treatment Plan	
	Yes	
No	

	Yes	
No	

		
with the following limitations:	

	

	

with the following limitations:	

	

	

		
with the following limitations:	

	

	

with the following limitations:	

	

	

	
	
<<Miscellaneous:Date (short)>>	

(Signature of patient)	
	
(Date)	

I, <<Doctor:Name>>, have discussed the plan and referral(s) with the patient	

(Full name of GP)	

	
<<Miscellaneous:Date (short)>>	

(Signature of GP)	
	
(Date)	

REVIEW 	
MBS ITEM NUMBER:   	
	
2712	
	
2719	

Planned date for review with GP
(initial review 4 weeks to 6 months after completion of plan)		
Actual date of review with GP		
Assessment/outcome tool results on review,  
except where clinically inappropriate		
Comments
Consider:
•	Progress on goals and actions
•	Have identified actions been initiated and followed through? e.g. referrals, appointments, attendance
•	Checking, reinforcing and expanding education
•	Communication
•	Where appropriate, communication received from referred practitioners
•	Modification of treatment plan if required		
Intervention/relapse prevention plan (if appropriate)
Consider:
•	Identify warning signs from past experiences
•	Note arrangements to intervene in case of relapse or crisis
•	Other support services currently in place
•	Note any past effective strategies