Mental Health Stepped Care Referral Form
Date: <TodaysDate>
Eligibility Criteria		Client prefers to be seen at:	
<Eligibility Criteria> <Low Income (eg Health Care Card, Disability Support Pension, or no source of income)  and / or> Low Income
Relevant card no. <Relevant Card # only if Low income>  
<Low to moderate suicide risk> Low to moderate suicide risk (Low income criteria is not applicable)
<Medicare Card Holder or> Medicare Card Holder
<Asylum Seeker> Asylum Seeker
<Client residing or working in EMPHN catchment>  Resides or works within EMPHN catchment
		<Client Prefers to be seen at:>

Preferred support method: <Or client prefers other support / contact method>	

1.	REFERRER DETAILS
Referrer name: <DrName>       Relationship to Client: <Referrers Relationship to Client>

Organisation: <Practice>  
Address: <UsrAddress> 

Phone: <UsrPhone>  Fax: <UsrFax>

2. CLIENT DETAILS

First Name: <PtFirstName>        Surname: <PtSurname>

DOB: <PtDoB>      Gender: <PtSex>      Phone: <PtPhoneH> / <PtPhoneMob>

<PtEthnicity>Email: <PtEmail>

Address: <PtAddress>

 Ethnicity: <PtEthnicity> 
Culturally and Linguistically Diverse Background  <Culturally and Linguistically Diverse Background> 
Country of Birth: <Country of Birth>      Interpreter Required (Language/Auslan): <Interpreter Required (Language/Auslan):>

Income Source: <Income Source>      Mobility/Disability Needs: <Mobility/Disability Needs>

Homelessness: <Homelessness:>           Comments: <Homelessness Comments>

NDIS package approved: <NDIS package approved>  Comments: <NDIS Comments>

2.	EMERGENCY CONTACT
If the client is a child, please provide the details of the parent or guardian who is responsible for decisions about treatment.

First Name: <Emergency Contact - First name>        Surname: <Emergency Contact - Surname>
Gender: <Emergency Contact Gender>          Relationship to Client: <Emergency Contact Relationship to Client>

Phone: <Emergency Contact Phone>      Email: <Emergency Contact Email>

3. CONSENT

<Client consent for sharing information: see form>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 to sharing de-identified data with DOH>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.
	
Please list all health professionals involved in client’s care and client/parent/guardian consent for EMPHN to contact them for the purposes of seeking collateral information: e.g. psychiatrist, GP, CAT team, allied health professionals etc.
	
Name	
Organisation	
Contact details	
Consent for contact 	

<List all providers involved in patient care: Please select>	
<Name 1>	
<Organisation 1>	
Phone: <Phone1>
Fax: <Fax 1>	
<Consent for Contact 1>	

<Select a 2nd provider (if applicable)>	
<Name 2>	
<Organisation 2>	
Phone: <Phone 2>
Fax: <Fax 2>	
<Consent for Contact 2>	

 Or verbal consent provided 

Client Signature:  ___________________________________                                                         Date: <TodaysDate>

Referrer Signature: _________________________________                                                          Date: <TodaysDate>

3.	CLINICAL INFORMATION <CLINICAL INFORMATION>
<Mental Health Treatment Plan attached> Mental Health Treatment Plan attached
Note: Only complete this section if this information has not been provided in a Treatment Plan
Presenting Issues: <TodaysVisit> <Visits>	
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): <SelectedRx>	
Relevant Medical History: <SelectedPMH>	
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 (MUST BE COMPLETED)
<RISK ASSESSMENT: MUST BE COMPLETED                    If your client is presenting in an acute psychiatric crisis or risk is high, please call your local area mental health service>

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

Current Suicidal Thoughts:  <Current Suicidal Thoughts>
Current Suicidal Plan: <Current Suicidal Plan>             
Current Suicidal Intent: <Current Suicidal Intent:>  
Recent Suicide attempt in the last three months? <Recent Suicide attempt in the last three months?>
Relevant History:  <Relevant History>
                       Suicide Risk Level:    <SUICIDE RISK LEVEL> 	
Current Self Harm Thoughts:    <Current self harm thoughts>
Current Self Harm Plan:             <Current self harm plan>
Current Self Harm Intent:          <Current self harm intent>
Current behaviours: <Current behaviours>
Relevant History: <Relevant History>
                      Self-Harm Risk Level: <SELF HARM RISK LEVEL> 	
Current Harm to Others Thoughts: <Current Harm to Others Thoughts> 
Current  Harm to Others Plan:  <Current harm to others plan>
Current  Harm to Others Intent:   <Current harm to others intent>
Relevant History: <Relevant history>
                      Risk to others:  <RISK TO OTHERS>  	
Risk of harm from others:  <Risk of harm from others>
Comments:<Comments>	
CURRENT RISK MANAGEMENT PLAN
<Current Risk management plan> , date of plan: <Date of plan>
If no plan, preparation of plan will be completed on <If no plan, plan will be completed on>  By: <Plan to be completed by:>
If no plan in place, please comment: <If no plan in place, please comment>  	

Comments: <Comments>
<Please attach any relevant/supporting documentation: Mental Health Care Plan, Assessment notes/Outcome measure/Discharge summary>
<Please ensure the referral is signed by both patient and clinician before faxing>