PHN Mental Health Intake
Sunshine Coast

For further information on Stepped Care services, see HealthPathways.

For any questions, please call PHN Mental Health Intake on 1300 747 724 or email on 
mentalhealthintake@ourphn.org.au

Secure electronic transfer to: (PS4558000Y8)
Alternatively fax to: 1300 787 494

Referrer Details
Referrer Name: | <<Doctor:Name>> | Date of Referral: | <<Miscellaneous:Date (short)>>
Referrer Position/Profession: | <<Doctor:Qualifications>> | Referrer Provider Number: | <<Doctor:Provider Number>>
Name of referring practice: | <<Practice:Name>> | Referrer phone: | <<Doctor:Phone>>
Referrer Address: | <<Doctor:Full Address>> | |
Client Information
Has client given consent for referral?

Client Name: | <<Patient Demographics:Full Name>>

DOB: | <<Patient Demographics:DOB>> | Age: | <<Patient Demographics:Age>> | Sex: | <<Patient Demographics:Gender>>
Ethnicity: | <<Patient Demographics:Ethnicity>> | Preferred Language: | <<Patient Demographics:Language Preferred>> | Interpreter required | <<Patient Demographics:Requires Interpreter>>
Address: | <<Patient Demographics:Address>>
| Suburb: | <<Patient Demographics:City>> | Postcode: | <<Patient Demographics:Postcode>>
Client | Mobile: | <<Patient Demographics:Phone (Mobile)>>
Contact | Home: | <<Patient Demographics:Phone (Home)>>
Details | 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 No. |
Marital Status: | <<Patient Demographics:Marital Status>>
Medication: | <<Clinical Details:Medication List>>
Allergies: | <<Clinical Details:Allergies/Adverse Reactions>>
Risk Information
Current suicidal ideation? | | Self- harm? |
Past suicide attempt? | | Mental health hospital admission in the last 12 months? |
In the last 7 days? | | Risk of harm to others? |
Demographic Information
Rural and Remote resident | | Culturally and Linguistically Diverse background |
Aboriginal and/or Torres Strait Islander | | LGBTIQ community member |
Female with Perinatal depression | | Financially disadvantaged (e.g. concession card holder) |
Affected by Domestic Violence | | Homeless (e.g. sleeping rough or couch surfing) |
NDIS participant | | DVA card holder |
Private health insurance | | To your knowledge, has the patient seen a psychologist this calendar year under Better Access? |
Referral Information

Which stream of support do you believe this person will be eligible for?

Reason for referral:

Assessments

Please indicate the score of any assessments undertaken: |
Kessler Psychological Distress Scale (K10+) |
Kessler 5 Psychological Distress Scale (K5 - for Aboriginal and Torres Strait Islander people) |
Short Form Survey (SF-12) |
Health of the Nation Outcome Scale (HoNOS) |
Patient Health Questionnaire (PHQ-9) |
General Anxiety Disorder-7 (GAD-7) |
Suicidal Ideation Attributes Scale (SIDAS) |
Strengths and Difficulties Questionnaire (SDQ) |
Other |

GP Mental Health Treatment Plan
Please attach, or copy and paste below, patient's Mental Health Treatment Plan (if applicable)