Date: <TodaysDate>
Eligibility Criteria  <Eligibility Criteria> 		Consumer prefers to be seen at:	
<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
<Resides or works within EMPHN catchment> - Resides or works within EMPHN catchment		<Consumer Prefers to be seen at:>

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

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

Organisation: <Practice>  
Address: <UsrAddress> 

Phone: <UsrPhone>  Fax: <UsrFax>
2.	  CONSUMER 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>

3.	EMERGENCY CONTACT
If the consumer 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 Consumer: <Emergency Contact Relationship to Consumer>

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

4.	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 consumer is presenting in an acute psychiatric crisis or risk is high, please call your local area mental health service>

If your consumer 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>

CONSENT <CONSENT>
Consent to Participate: Eastern Melbourne PHN (EMPHN) and providers who run services that EMPHN funds are required to collect and use information about you. This includes personal inforamtion, and information about the services you are receiving. This information is used by staff members involved in delivering services to you, and by staff at EMPHN. This information is used and shared to ensure you get the right service for your needs, to monitor service delivery and performance, and evaluate and make improvements to services. This consent condition is mandatory - to receive services, you must agree.  
I/parent/guardian consents to receive services and for the collection and use of information aboutme and the services I receive, as outlined above.     <Consent to Participate: I/parent/guardian consent to receive services and for the collection and use of information about me and the services I receive, as outlined on the form.>
EMPHN funded services are evaluated to ensure th are meeting the needs of consumers and our community. You may be contacted to participate in additional evaluation activities associated with your care. If contacted, you can choose whether you wish to take part or not. 	
Consent to collect and share information with other services: 
I/parent/guardian consents to the collection and sharing of all relevant information with other service providers relevant to assist my/my child's overall care. I understand that my information willnot be sharded if I do not consent.                      <Consent to collect and share inforamtion with other services: I/parent/guardian consents to the collection and sharing of all relevant information with other service providers relevant to assist my/my child's overall care. I understand that my inforamtion will not be shared if I do not consent.>
If YES, please list all service providers you consent to being contacted by EMPHN or EMPHN's funded service provider and discussing your/your child's care (e.g. GP, Psychiatrist, CAT team, allied health professionals etc.)
	
Name	
Organisation	
Contact details	

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

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

Consent to share anonymised data with the Department of Health: 
As the overall funder, the Department ofhealth is interested in anonymised data which will be used for evaluation purposes to improve mental health services in Australia. This anonymised data includes information about you, such as your gender, date of birth and types of services received, but does not include any infromation that could identify you (e.g. your name, address or Medicare number). 
I/parent/guardian consents to EMPHN providing anonymised data about me and the services I receive to the Department of Health. I understand that my information willnot be shared if I do not consent.  <Consent to share anonymised data to Department of Health>

Client Signature: __________________________________________________________        Date: <TodaysDate>

<Verbal consent provided by consumer> Verbal consent provided by consumer  Referrer Signature: _______________________ Date: <TodaysDate>

<Please ensure the referral is signed by both consumer and referrer before faxing>