Re: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>> 
DOB: <<Patient Demographics:DOB>>
-------------------
PHN Mental Health Intake
Wide Bay	

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 to: PW45580006G 
PHN Mental Health WB (PW45580006G)	

Alternatively fax to: 1300 787 494	

Referrer Details	

Referrer Name:
	
<<Doctor:Name>>	
Date of Referral:	
<<Miscellaneous:Date (short)>>	

Referrer Position/Profession:	
<<Doctor:Qualifications>>	
Referrer Provider Number:	
<<Doctor:Provider Number>>	

Name of referring practice:	
<<Practice:Name>>	
Referrer phone:	
<<Doctor:Phone>>	

Referrer Address:
	
<<Doctor:Full Address>>	

 Client Information 	

 Has client given consent for referral?	

Client Name:	
<<Patient Demographics:Full Name>>	

 DOB:	
<<Patient Demographics:DOB>>	
Age:	
<<Patient Demographics:Age>>	
Sex:	
<<Patient Demographics:Gender>>	

 Ethnicity:	
<<Patient Demographics:Ethnicity>>	
Preferred Language:	
<<Patient Demographics:Language Preferred>>	
Interpreter required	
<<Patient Demographics:Requires Interpreter>>	

 Address:	
<<Patient Demographics:Address>>

	
Suburb:	
<<Patient Demographics:City>>
	
Postcode:	
<<Patient Demographics:Postcode>>

 Client 	
Mobile:	
<<Patient Demographics:Phone (Mobile)>>	

 Contact 	
Home:	
<<Patient Demographics:Phone (Home)>>	

 Details	
Work:	
<<Patient Demographics:Phone (Work)>>	

Email:	
<<Patient Demographics:E-mail>>	

 Medicare No.	
<<Patient Demographics:Medicare Number>>	
DVA number	
<<Patient Demographics:DVA Number>>	

 Health Care Card     No.	
<<Patient Demographics:Pension Number>>	
Private Health No.	

 Marital Status:        	
<<Patient Demographics:Marital Status>>	

 Medication:	
<<Clinical Details:Medication List>>	

 Allergies:	

<<Clinical Details:Allergies/Adverse Reactions>>	

Risk Information	

Current suicidal ideation?	
	
Self- harm? 	

Past suicide attempt?	
	
Mental health hospital admission in the last 12 months? 	

In the last 7 days?	
	
Risk of harm to others?	

Demographic Information	

Rural and Remote resident	
	
Culturally and Linguistically Diverse background	

Aboriginal and/or Torres Strait Islander 	
<<Patient Demographics:ATSI>>	
LGBTIQ community member	

Female with Perinatal depression	
	
Financially disadvantaged (e.g. concession card holder)	

Affected by Domestic Violence	
	
Homeless (e.g. sleeping rough or couch surfing)	

NDIS participant	
	
DVA card holder	

Private health insurance	
	
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?	

	

Reason for referral:	

	

Assessments	

Please indicate the score of any assessments undertaken: 

Kessler Psychological Distress Scale (K10+)

Kessler 5 Psychological Distress Scale (K5 - for Aboriginal and Torres Strait Islander people)

Short Form Survey (SF-12)

Health of the Nation Outcome Scale (HoNOS)

Patient Health Questionnaire (PHQ-9)

General Anxiety Disorder-7 (GAD-7)

Suicidal Ideation Attributes Scale (SIDAS) 

Strengths and Difficulties Questionnaire (SDQ)

Other 	

	

GP Mental Health Treatment Plan	

Please attach, or copy and paste below, patient's Mental Health Treatment Plan (if applicable)