RE:<PtFirstName> <PtSurname>
DOB:<PtDoB>
****************

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 

Send via Medical Objects: PS4558000Y8 
PHN MENTAL HEALTH SC (PS4558000Y8)

Alternatively fax to: 1300 787 494	
Referrer Details	
Referrer Name:	<DrName>	Date of Referral:	<TodaysDate>	
Referrer Position/Profession:	GP	Referrer Provider Number:	<DrProviderNo>	
Name of referring practice:	<Practice>	Referrer phone:	<UsrPhone>	
Referrer Address:	<UsrAddress>	
 Client Information 	
Has client given consent for referral?  <Has the patient given consent for a referral to the Central Intake team, for assessment and triaging into a Mental Health Stepped Care Service stream?>	
Client Name:	<PtFullName>	
DOB:	<PtDoB>	Age:	<PtAge>	Sex:	<PtSex>	
Ethnicity:	<PtEthnicity>	Preferred Language:	<Preferred language>	Interpreter required	<Interpreter required?>	
Address:	<PtAddress>				
	Suburb:	<PtCity>	Postcode:	<PtPostcode>	
Client Contact Details	Mobile:	<PtPhoneMob>	
	Home:	<PtPhoneH>	
	Work:	<PtPhoneWk>	
	Email:	<PtEmail>	
Medicare No.	<PtMCNo>	DVA number	<PtDVANo>	
Health Care Card No.	<PtPensionNo>	Private Health No.	<PtInsNo>	
Marital Status:	<PtMaritalSt>	
Medication:	 <SelectedRx>

Allergies:	<Reactions>

Risk Information	
Current suicidal ideation? <Current suidical ideation?>
Past suicide attempt? <Past suicide attempt?> 
In the last 7 days?  <Suicide attempt in last 7 days?>	Self- harm? <Self-harm?>
Mental health hospital admission in the last 12 months? <Mental health hospital admission in last 12 months?>
Risk of harm to others? <Risk of harm to others?>	
Demographic Information	
Rural and Remote resident	<Rural or remote resident>	Culturally and Linguistically Diverse background	<Culturally and Linguistically Diverse background>	
Aboriginal and/or Torres Strait Islander 	<Aboriginal and/or Torres Strait Islander>	LGBTIQ community member	<LGBTIQ community member>	
Female with Perinatal depression	<Female with Perinatal depression>	Financially disadvantaged (e.g. concession card holder)	<Financially disadvantaged (e.g. concession card holder)>	
Affected by Domestic Violence	<Affected by Domestic Violence>	Homeless (e.g. sleeping rough or couch surfing)	<Homeless (e.g. sleeping rough or couch surfing)> 	
NDIS participant	<NDIS participant>	DVA card holder	<DVA card holder>	
Private health insurance	<Private health insurance>	To your knowledge, has the patient seen a psychologist this calendar year under Better Access? 	<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? 
<Which stream of support do you believe this person will be eligible for?>
	
Reason for referral:
<Reason for referral and mental health history:>

	
Assessments	
Please indicate the score of any assessments undertaken: 
<Have any assessments been completed with the patient?>
Kessler Psychological Distress Scale (K10+) <Kessler Psychological Distress Scale (K10+)>
Kessler 5 Psychological Distress Scale (K5 - for Aboriginal and Torres Strait Islander people) <Kessler 5 Psychological Distress Scale (K5)>
Short Form Survey (SF-12) <Short Form Survey (SF-12)>
Health of the Nation Outcome Scale (HoNOS) <Health of the Nation Outcome Scale (HoNOS)>
Patient Health Questionnaire (PHQ-9) <Patient Health Questionnaire (PHQ-9)>
General Anxiety Disorder-7 (GAD-7) <General Anxiety Disorder-7 (GAD-7)>
Suicidal Ideation Attributes Scale (SIDAS) <Suicidal Ideation Attributes Scale (SIDAS)>
Strengths and Difficulties Questionnaire (SDQ) <Strengths and Difficulties Questionnaire (SDQ)>
Other <Other (assessment name and score)>	
GP Mental Health Treatment Plan	
Please attach, or copy and paste below, patient's Mental Health Treatment Plan (if applicable)