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

Re: <PtFirstName> <PtSurname>   DOB: <PtDoB>

PHN Mental Health Intake Stepped Care services 
(version 3.0 - January 2023)

For support completing this referral form: 
•	Refer to HealthPathways
•	Call PHN Head to Health on 1300 747 724 / 1800 595 212
•	Email headtohealth@c2coast.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  
 <I understand PHN no longer requires a GP referral to access PHN funded psychological therapies. Patients can self-refer by calling 1800595212. PHN continues to accept referrals from GPs. GPs can refer direct to PHN service providers.>  I understand PHN no longer requires a GP referral to access PHN funded psychological therapies. Patients can self-refer by calling 1800595212. PHN continues to accept referrals from GPs. GPs can refer direct to PHN service providers

<I understand that Head to Health is NOT a crisis service. Our operating hours are Monday - Friday, 8.30am - 5pm. Patients in crisis should be referred to the local Acute Care Team by calling 1300MHCALL. If an emergency call 000> I understand that Head to Health is NOT a crisis service. Our operating hours are Monday - Friday, 8.30am - 5pm. Patients in crisis should be referred to the local Acute Care Team by calling 1300MHCALL. If an emergency call 000

<I understand patients can self-refer by calling Head to Health on 1800595212 and will be assessed (if appropriate) using the Initial Assessment and Referral Decision Support Tool (IAR DST)> I understand patients can self-refer by calling Head to Health on 1800595212 and will be assessed (if appropriate) using the Initial Assessment and Referral Decision Support Tool (IAR DST)

<For clients at risk of accepting calls from Head to Health (eg Domestic and Family Violence clients): Please consider asking the client to call 1800 595 212 at an appropriate time or direct refer to service providers.> For clients at risk of accepting calls from Head to Health (eg Domestic and Family Violence clients): Please consider asking the client to call 1800 595 212 at an appropriate time or direct refer to service providers. 

<Referrals to PHN funded low intensity and pyschological therapy services are only available for underserviced groups (refer to Health Pathways 'Stepped Care Page'). PHN may suggest Better Access in some cases> Referrals to PHN funded low intensity and pyschological therapy services are only available for underserviced groups (refer to Health Pathways 'Stepped Care Page'). PHN may suggest Better Access in some cases 

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>
Referrer address | <UsrAddress>

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?*>
Has consent been provided for Head to Health to contact the client?  <Can PHN contact the client/guardian?>
Have you advised the client that a member of the Head to Health team will be calling them from a 'NO CALLER ID' number to discuss their referral details? <Have you advised the client that a member of the Head to Health team will be calling them from a 'NO CALLER ID' number to discuss their referral details?> 

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: <Please provide details of substance and alcohol 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. I have completed a provisional risk assessment below <I have completed a 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)
<Initial Assessment and Referral Decision Support Tool Level of Care> | Initial Assessment and Referral Decisions support tool Level of Care (IAR DST) IAR DST
<Other> | Other – please specify  <If 'Other' - please specify>

GP Mental Health Treatment Plan

NOTE: A GP mental health treatment plan is not required for a referral to Head to Health, however it may be a requirement of the service towhich the client is on-referred (eg. if Better Access is identified as the best option).