RE: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
DOB: <<Patient Demographics:DOB>>
****************

IWC Indigenous Stepped Care (ISCP) 
Mental Health Referral Form 

For further information on Stepped Care services, please see HealthPathways.

For any questions, please call IWC on 1300 492 492 or email indigenoussteppedcare@iwc.org.au

Please send via: 

Medical Objects: SI46700007L         
Fax: 07 3811 6459	
Referrer Details	
Referrer:	<<Doctor:Name>>	Date of Referral:	<<Miscellaneous:Date>>	
Referrer Position/Profession:	GP	Referrer Provider Number:	<<Doctor:Provider Number>>	
Referring practice:	<<Practice:Name>>	Referrer phone:	<<Doctor:Phone>>	
Referrer Address:	<<Doctor:Address>>	
 Client Information 	
Has client given consent for referral?  <Has the patient given consent for a referral to the Central Intake team, for assessment and triaging into a Mental Health Stepped Care Service stream?>	
Client Name:	<<Patient Demographics:Full Name>>	
DOB:	<<Patient Demographics:DOB>>	Age:	<<Patient Demographics:Age>>	Sex:	<<Patient Demographics:Gender>>	
Ethnicity:	<<Patient Demographics:Ethnicity>>	Preferred Language:
Interpreter required?:	<<Patient Demographics:Language Preferred>>
<<Patient Demographics:Requires Interpreter>>			
Address:	<<Patient Demographics:Address>>	

Suburb:	
<<Patient Demographics:City>>	
Postcode:	
<<Patient Demographics:Postcode>>	

Client Contact Details	Mobile:	
<<Patient Demographics:Phone (Mobile)>>	

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

Work:	
<<Patient Demographics:Phone (Work)>>	

Email:	
<<Patient Demographics:E-mail>>	

Medicare No.	<<Patient Demographics:Medicare Number>>	DVA number	<<Patient Demographics:DVA Number>>	
Health Care Card No	<<Patient Demographics:Pension Number>>	Private Health	<<Patient Demographics:Health Insurance>>	
Marital Status:	<<Patient Demographics:Marital Status>>	
Medication:	 <<Clinical Details:Medication List>>	
Allergies:	<<Clinical Details:Allergies/Adverse Reactions>>
	
Risk Information	
Current suicidal ideation? <<Current suicidal ideation?>>
Past suicide attempt? <<Past suicide attempt?>>
In the last 7 days?  <<Suicide attempt in the last 7 days?>>	Self- harm? <<Self harm?>>
Mental health hospital admission in the last 12 months? <<Mental health hospital admission in last 12 months?>> 
Risk of harm to others? <<Risk of harm to others?>>	
Demographic Information	
Rural and Remote resident	<<Rural or remote resident>>	Culturally and Linguistically Diverse background	<<Culturally and linguistically diverse background>>	
Aboriginal and/or Torres Strait Islander 	<<Aboriginal and/or Torres Strait Islander?>>	LGBTIQ community member	<<LGBTIQ community member>>	
Female with perinatal depression	<<Female with perinatal depression>>	Financially disadvantaged (e.g. concession card holder)	<<Financially disadvantaged (e.g. concession card...)>>	
Affected by domestic violence	<<Affected by domestic violence>>	Homeless (e.g. sleeping rough or couch surfing)	<<Homeless (e.g. sleeping rough or couch surfing)>>	
NDIS participant	<<NDIS participant>>	DVA card holder	<<DVA card holder>>	
Private health insurance	<<Private Health Insurance>>	To your knowledge, has the patient seen a psychologist this calendar year under Better Access? 	<<Seen psychologist this year under Better Access?>>	
Referral Information	
Which stream of support do you believe this person will be eligible for? 
<<Which stream of support seems most appropriate?>>

Reason for referral:
<<Reason for referral and mental health history:>>	
Assessments	
Please indicate the score of any assessments undertaken: 
Have any assessments been completed with the patient? <<Have any assessments been completed?>>
Kessler Psychological Distress Scale (K10+): <<Kessler Psychological Distress Scale (K10+)>>
Kessler 5 Psychological Distress Scale (K5 - for Aboriginal and Torres Strait Islander people): <<Kessler 5 Psychological Distress Scale (K5)>>
Short Form Survey (SF-12): <<Short Form Survey (SF-12)>>
Health of the Nation Outcome Scale (HoNOS): <<Health of the Nation Outcome Scale (HoNOS)>>
Patient Health Questionnaire (PHQ-9): <<Patient Health Questionnaire (PHQ-9)>>
General Anxiety Disorder-7 (GAD-7): <<General Anxiety Disorder 7 (GAD-7)>>
Suicidal Ideation Attributes Scale (SIDAS): <<Suicidal Ideation Attributes Scale (SIDAS)>>
Strengths and Difficulties Questionnaire (SDQ): <<Strengths and Difficulties Questionnaire (SDQ)>>
Other: <<Other (assessment name and score)>>	
GP Mental Health Treatment Plan	
Please attach, or copy and paste below, patient's Mental Health Treatment Plan (if applicable)