Mental Health Stepped Care Referral Form
Date: <<Miscellaneous:Date (short)>>
Eligibility Criteria	
<<Eligibility Criteria>>
Client prefers to be seen at:
<<Client prefers to be seen at>> OR
 Client preferred form of contact <<OR Client Prefers other form of contact>>	
1. REFERRER DETAILS
Referrer name: <<Miscellaneous:Current User>>     Relationship to Client: <<Referrers Relationship to Client>>
Organisation:  <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>     Fax: <<Practice:Fax>>

2. CLIENT DETAILS
First Name: <<Patient Demographics:First Name>>      Surname: <<Patient Demographics:Surname>>
DOB: <<Patient Demographics:DOB>>     Gender: <<Patient Demographics:Gender>>     Phone: <<Patient Demographics:Phone (Home)>>/ <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>
Address: <<Patient Demographics:Full Address>>
 Aboriginal/Torres Strait Islander background: <<Aboriginal/Torres Strait Islander>>     
Culturally and Linguistically Diverse Background: <<Culturally and Linguistically Diverse Background>>   
Country of Birth: <<Patient Demographics:Country of Birth>>  Interpreter Required (Language/Auslan):    
Income Source:       Mobility/Disability Needs: 
Homelessness:       Comments:  
NDIS package approved:       Comments: 

3. EMERGENCY CONTACT
If the client is a child, please provide the details of the parent or guardian who is responsible for decisions about treatment.
<<Emergency Contact>>
<<Name>> <<Contact>>
<<Relationship to Client>>

CONSENT

<<Client Consent>>  Client / parent / guardian consents to Eastern Melbourne PHN (EMPHN) to seek, collect and share their relevant health information to the appropriate service provider(s) for the purpose of referral for ongoing care.
	
<<Client Consent de-identified data>>  Client / parent / guardian consents to their/ their child's de-identified information being used by EMPHN for evaluation and reporting purposes to the Department of Health. They understand this data, which does not include their name, address or Medicare number, but will include information such as date of birth, gender and types of services they use, will be used for the purposes of improving health services in Australia. Client understands that their/ their child's information will not be provided to the Department of Health if they indicate they do not consent.
	
Health Professionals involved in the clients care:
<<Health Professional #1>>
<<Health Professional #2>>

ClientSignature____________________________Date: <<Miscellaneous:Date (short)>>
Referrer Signature: _________________________________                          Date: <<Miscellaneous:Date (short)>>

1.	CLINICAL INFORMATION <<CLINICAL INFORMATION>>

Presenting Issues: <<Summary:Progress Notes (Selected)>>	
Reason for Referral to Stepped Care: <<Reason for Referral to Stepped Care>>	
Mental Health Diagnosis (if known): <<Mental Health Diagnosis (if known)>>	
Medication (if known): <<Clinical Details:Medication List>>	
Relevant Medical History: <<Clinical Details:History List>>	
Substance Use: <<Substance Use>>	
Other Impacting factors:  <<Other Impacting factors>>	

Please attach any relevant/supporting documentation: Mental Health Care Plan, Assessment notes/Outcome measure/Discharge summary

RISK ASSESSMENT
If your client is presenting in an acute psychiatric crisis or risk is high, please call your local area mental health service 

Risk Assessment- Suicide <<Risk Assessment Suicide>>
	
Risk Assessment- Self Harm <<Risk Assessment Self Harm>>

                                	
Risk Assessment- Harm to others <<Risk Assessment Harm to others>>

                                	
CURRENT RISK MANAGEMENT PLAN
<<Current Risk Management Plan>>,    date of plan, if complete: <<Date of Plan>>
If no plan, preparation of plan will be completed on <<If no plan, preparation of plan will be completed on>> By: <<Plan to be completed by>>
Please comment: <<If risk mnagement plan not applicable, comment>> 	

Comments: <<Additional Comments>>

<<Signatures Required>>