Mental Health Stepped Care Referral Form
Date: <<Miscellaneous:Date (short)>>
Eligibility Criteria	
 <<Eligibility Criteria>>

Consumer prefers to be seen at	
<<Consumer prefers to be seen at>> 
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.	CONSUMER 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: <<Patient Demographics:ATSI>>
Culturally and Linguistically Diverse Background: <<Culturally and Linguistically Diverse Background>>   
Country of Birth: <<Patient Demographics: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 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>>

4.	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>>

                                	
Risk of harm from others: <<Risk of harm from others>>	
CURRENT RISK MANAGEMENT PLAN
<<Current Risk Management Plan in place>>,    date of plan: <<Date of Plan>>
No Plan in place, 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, Comments>> 	

Comments: <<Additional Comments>>

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 information, 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 inforamtion 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.    

<<Consent to participate>>  
EMPHN funded services are evaluated to ensure they are meeting the needs of consumer 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:
<<Consent to share information with other services>> 

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,Psychiatirst, CAT team, Allied health professionals etc.). 	
Health Professionals involved in the clients care:
<<Health Professional #1>>
<<Health Professional #2>>
	
Consent  to share anonymised data with the Department of Health: 
As the overall funder, the Department of Health 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 information that could identify you (e.g. your name, address or Medicare number). 

<<Client Consent to de-identified data>>

Client Signature______________________________Date: <<Miscellaneous:Date (short)>>
Verbal consent provided by consumer: <<Verbal Consent Provided by Consumer >>  
Referrer Signature: __________________________  Date: <<Miscellaneous:Date (short)>>

<<Signatures Required>>