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: <MBS Item 2700:> 2700  <MBS Item 2701:> 2701  <MBS Item 2715:> 2715  <MBS Item 2717:> 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.
Here is a printable version of the E-MENTAL HEALTH PATIENT INFORMATION BROCHURE for your patients	
CONTACT AND DEMOGRAPHIC DETAILS	
GP name	<DrName>	GP phone	<DrPhone>	
GP practice name	<Practice>	GP fax	<DrFax>	
GP address	<DrAddress>	Provider number	<DrProviderNo>	
Relationship	This person has been my patient since	
<This person has been my patient since>	

and/or	

This person has been a patient at this practice since	
<This person has been a patient at this practice since>	

Patient surname	<PtSurname>	Date of  birth (dd/mm/yy)	<PtDoB>
	
Patient first name(s)	<PtFirstName>	Preferred name	<PtPrefName>	
Gender	<PtSex>   <Self-identified gender> Self-identified gender:<Self-identified gender details>	
Patient address	<PtAddress>	
Patient phone	Preferred number: <Preferred phone number:>

Can leave message?   <Can leave message?>	Alternative number: <Alternative phone number:>

Can leave message?   <Alternative number: Can leave message?>	
Medicare No.	<PtMCNo>	Healthcare Card/Pension No.	<PtPensionNo>	
Parent/guardian details 	Has patient consented for this Treatment Plan to be released to parents/guardians?	
First parent/guardian:
<1. Parent/guardian:>
	Relationship:
<1. Parent/guardian relationship:>	Phone number 1:
<1. Parent/guardian phone number 1:>
Phone number 2:
<1. Parent/guardian phone number 2:>

	<Patient consented for plan to be released to parent/guardian>

With the following restrictions:<With the following restrictions:>	
Second parent/guardian:
<2. Parent/guardian:>	Relationship:
<1. Parent/guardian relationship:>	Phone number 1:
<1. Parent/guardian phone number 1:>
Phone number 2:
<1. Parent/guardian phone number 2:>	<Patient consented for plan to be released to parent/guardian>

With the following restrictions:<With the following restrictions:>	
Emergency contact person details	Has patient consented for this healthcare team to contact emergency contacts?	
First contact:
<1. Emergency contact name:>	Relationship:
<1. Emergency contact relationship:>	Phone number 1:
<1. Emergency phone number 1:>
Phone number 2:
<1. Emergency phone number 1:>	 <Has patient consented to contact emergency contacts?>	
Second contact:
<2. Emergency contact name:>	Relationship:
<2. Emergency contact relationship:>	Phone number 1:
<2. Emergency phone number 1:>
Phone number 2:
<2. Emergency phone number 2:>
	<Has patient consented to contact emergency contacts?>	
Schooling (if applicable)	
Current school level	<Current school level>	Name of school/pre-school	<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	<Salient school factors>	
Patient/guardian consent to discuss GPMHTP with the following members of school community:	
<Consent>	Role	Name(s)	Phone	
<Yes: Principal> Yes	Principal	<Principal Name(s):>	<Principal Phone:>	
<Yes: Assistant Principal(s)> Yes	Assistant Principal(s)	<Assistant Principal Name(s):>	<Assistant Principal(s) Phone:>	
<Yes: Teacher(s)> Yes	Teacher(s)	<Teacher(s) Name(s):>	<Teachers Phone:>	
<Yes: School Counsellor(s)> Yes	School Counsellor(s)	<School Counsellor(s) Name(s):>	<School Counsellor(s) Phone:>	
<Yes: Other> Yes	Other	<Other Name(s):>	<Other Phone:>	
SALIENT COMMUNICATION AND CULTURAL FACTORS	
Language spoken at home	 <Language spoken at home>	 Other:<Other:>	
Interpreter required	 <Interpreter required>	 Yes, Comments: <Yes, Comments:>	
Country of birth	 Australia	 Other: <Country of birth (if not Australia):>	
Other communication issues	<Other communication issues>	
Other cultural issues	<Other cultural issues>	

PATIENT ASSESSMENT – MENTAL HEALTH	
Reasons for presenting
Consider:
•	What are the patient’s current mental health issues?
•	Requests and hopes	<Reasons for presenting>	
History of current episode
Consider:
•	Symptom onset, duration, intensity, time course	<History of current episode>	
Patient history
Consider:		
•	Mental health history 	<Mental health history>	
•	Salient social history	<Salient social history>	
•	Salient medical/biological history 
•	♀ - menarche, menstruation, pregnancy, menopause	<Salient medical/biological history>	
•	Salient developmental issues	<Salient developmental issues>	
Family history of mental illness
Consider:
•	Family history of suicidal behaviour
•	Genogram	<Family history of mental illness>	
Current domestic and social circumstances
Consider:
•	Living arrangements
•	Social relationships
•	Occupation	<Current domestic and social circumstances>	
Salient substance use issues
Consider:
•	Nicotine use
•	Alcohol use
•	Illicit substances
•	Is patient willing to address the issues?	<Salient substance use 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?	<SelectedRx>	
History of medication and other treatments for mental illness
Consider:
•	Past referrals
•	Effectiveness of previous treatments
•	Side-effects and complications associated with previous treatments
•	Patient’s preference for medications	<History of meds and other treatments for mental illness>	
Allergies	<Reactions>	
Relevant physical examination and other investigations	<Relevant physical examination and other investigations>	
Results of relevant previous psychological and developmental testing	<Results of previous psychological and developmental testing>	
Other care plan
e.g.  GP Management Plans and Team Care Arrangements; 
Wellness Recovery Action Plan	 <Other care plan>  If yes Specify:  <If yes, please specify:>

Comments on Current Mental State Examination	
Consider:
•	Appearance, cognition, thought process, thought content, attention, memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation.
•	Appropriateness of Mini Mental State Examination for patients over 75 years or if otherwise indicated	
<Comments on Current Mental State Examination>	
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	
<Suicide: Ideation/ thoughts>
	
<Suicide: Intent>	
<Suicide: Plan>	

Self harm	
<Self harm: Ideation/ thoughts>	
<Self harm: Intent>	
<Self harm: Plan>	

Harm to others	
<Harm to others: Ideation/ thoughts>
	
<Harm to others: Intent>	
<Harm to others: Plan>	

Comments or details of any identified risks	

<Comments or details of any identified risks>	

Assessment/outcome tool used, 
except where clinically inappropriate.	<Assessment/outcome tool used>	
Date of assessment	<Date of assessment>	
Results
	<Results>

<Copy of completed tool provided to referred practitioner> Copy of completed tool provided to referred practitioner	
Provisional diagnosis of mental health disorder
Consider conditions specified in the ICPC, including:
•	Depression
•	Bipolar disorder
•	Other mood disorders
•	Anxiety disorders
•	Panic disorder
•	Phobic disorders
•	Post-traumatic stress disorder
•	Schizophrenia
•	Other psychotic disorders
•	Adjustment disorder
•	Dissociative disorders
•	Eating disorders
•	Impulse-control disorders
•	Sexual disorders
•	Sleep disorders
•	Somatoform disorders
•	Substance-related disorders
•	Personality disorders
•	Unknown	<Provisional diagnosis of mental health disorder>	
Case formulation
Consider:
•	Predisposing factors
•	Precipitating factors
•	Perpetuating factors
•	Protective factors	<Case formulation>	
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	<Other relevant information from carer/informants>	
Any other comments	<Any other comments>	

PLAN	
	Actions	
Identified issues/problems
Consider:
•	As presented by patient
•	Developed during consultation
•	Formulated by GP	Goals
Consider:
•	Goals made in collaboration with patient
•	What does the patient want to see as an outcome from this plan?
•	Wellbeing, function, occupation, relationships
•	Any reference to special outcome measures
•     Time frame	Treatments & interventions
Consider:
•	psychological interventions
•	face to face
•	internet based
•     <Treatments and Interventions: Internet Options> 
•	Suggested psychological interventions
•	Medications
•	Key actions to be taken by patient 
•	Support services to achieve patient goals
•	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
•	<Referral to Internet Mental Health Programs:>
•	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	
Issue 1: <Issue 1:>	<Issue 1: Goals>	<Issue 1: Treatments and interventions>	<Issue 1: Referrals>	<Issue 1: Any role of carer/support person(s)>	
Issue 2: <Issue 2:>	<Issue 2: Goals>	<Issue 2: Treatments and interventions>	<Issue 2: Referrals>	<Issue 2: Any role of carer/support person(s)>	
Issue 3: <Issue 3:>	<Issue 3: Goals>	<Issue 3: Treatments and interventions>	<Issue 3: Referrals>	<Issue 3: Any role of carer/support person(s)>	
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	<Intervention/relapse prevention plan>

<Prep of plan for delegation of patient’s responsibilities>Preparation of plan for delegation of patient’s responsibilities (e.g., care for dependants, pets)	
Psycho-education provided if not already addressed in “treatments and interventions” above?	<Psycho-education provided? Yes> Yes	<Psycho-education provided? No> No 	
Plan added to the patient’s records?	<Plan added to the patient’s records? Yes> Yes	<Plan added to the patient’s records? No> No	

Other healthcare providers and service providers involved in patient’s care<Other:>
(e.g. psychologist, psychiatrist, social worker, occupational therapist, other GPs, other medical specialists, case worker, community mental health services)	
Role	Name	Address	Phone	
<Other healthcare\service providers: Role>	<Other healthcare\service providers: Name>	<Other healthcare\service providers: Address>	<Other healthcare\service providers: Phone>	
<2. Other healthcare\service providers: Role>	<2. Other healthcare\service providers: Name>	<2. Other healthcare\service providers: Address>	<2. Other healthcare\service providers: Phone>	

COMPLETING THE PLAN	
On completion of the plan, the GP may record (tick boxes below) that s/he has:

<Discussed the assessment with the patient>  discussed the assessment with the patient
<Discussed aspects of the plan and the agreed date for review>  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>  offered a copy of the plan to the patient and/or their carer (if agreed by patient)
	 Date plan completed	

<Date plan completed>

	

RECORD OF PATIENT CONSENT	
I, ___________________________________________________(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	
	c with the following limitations:
	c
	 c with the following limitations:
	c
	
	c with the following limitations:
	c
	 c with the following limitations:
	c

__________________________________________
(Signature of patient)	
________/________/________
(Date)	

I, ________________________________________, have discussed the plan and referral(s) with the patient.
(Full name of GP)	

__________________________________________
(Signature of GP)	
________/________/________
(Date)	

REVIEW	
MBS ITEM NUMBER:   <MBS Item 2712:> 2712    <MBS Item 2719:> 2719	
Planned date for review with GP
(initial review 4 weeks to 6 months after completion of plan)	<Planned date for review with GP>	
Actual date of review with GP	<Actual date of review with GP>	
Assessment/outcome tool results on review,
except where clinically inappropriate

	<Assessment/outcome tool results on review>	
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
	<Comments>	
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	<Review: Intervention/relapse prevention plan>