MENTAL HEALTH GP REFERRAL FORMACCESS TO ALLIED PSYCHOLOGICAL SERVICES (ATAPS)To be completed by the GP and returned to GP down south by fax (08) 9754 2985For further enquiries phone: (08) 9754 3662Referral request details (please complete) MENTAL HEALTH CARE PLAN TO BE ATTACHEDREFERRAL REQUEST DETAILS (please complete)

Referral Date: Health Care Card #:Referring GP: Please indicate referral type:Address: Health Care Card Holder

Perinatal Depression Birth Date (due) of baby: Homelessness or at risk Aboriginal or Torres Strait Islander Child under 12 – diagnosed Mental Health Disorder (attach Mental Health Treatment Plan)

Phone: Fax:

PATIENT DETAILS (please complete)

Patient Name:DOB: Gender: Male FemaleAddress: Phone:

Email:Is this patient Aboriginal or Torres Strait Islander? Aboriginal or Torres Strait Islander

Does this person live on his or her own? Yes No

Main Language spoken at home:(only answer this question if patient has identified that they speak a language other than English)How well does the patient speak English? Very Well Well Not At All

Do they require an interpreter? Yes NoHighest level of education completed? Pre-Primary Primary Yr10 Yr12 Tertiary

ADDITIONAL DETAILS (please complete)Suicide Risk - Ideation: Yes No

Has the patient received Focused Psychological Services under Better Access in this calendar year? Yes - Name of Provider: No UnknownHas the patient ever received specialist Mental Health Care Before? Yes - Details: No UnknownCopy of current Mental Health Treatment Plan attached: Yes No

Outcome Tool & Result:

Does the patient have a history of violent or aggressive behavior? Yes No UnknownICD 10 Diagnostic Categories: Alcohol &Drug UseDisorders

PsychoticDisorders

Depression AnxietyDisorders

Post NatalDepression

UnexplainedSomaticDisorders

Unknown Other

Which focused psychological strategies (FPS) is the patient being referred for? DiagnosticAssessment

PsychoEducation

CognitiveIntervention(CBT)

BehavioralIntervention(CBT)

RelaxationStrategies(CBT)

SkillsTraining(CBT)

Other CBTInterventions

InterpersonalTherapy

NarrativeTherapy

Family Therapy(Perinatal Depression/Children) Behavior Management/Child Other: Please Specify:

Is the patient receiving psychotropic medication at referral? Benzodiazepines / anxiolytics Antidepressants (Incl. SSRIs, SNRIs and TCAs)

Phenothiazine’s / Tranquillisers (resperidone, olanzapine,clozapine, haloperidol, chlorpromazine)

Mood Stabilisers (Incl. lithium carbonate, sodium valproate,carbamazepine)

Yes I have discussed the ATAPS referral with my patient. GP to Sign and date:

17/07/2015

MENTAL HEALTH GP REFERRAL FORMACCESS TO ALLIED PSYCHOLOGICAL SERVICES (ATAPS)This form with completed treatment plan is to be returned to GP down south by fax (08) 9754 2985For further enquiries phone GP down south Mental Health Team on: (08) 9754 3662The patient must read and sign the consent form (below). The GP must also sign the consent form.Your GP has referred you to GP down south Mental Health ATAPS Program. The ATAPS Program is a free service delivered by GP down south for people with a mental illness who may not otherwise be able to access Mental Health services.

Participation in this program will require your GP and your Allied Health Professional to share information about your diagnosis and treatment.

For the purpose of evaluation and reporting, some of your personal information including name and date of birth, as well as information about the type of mental health concern you are experiencing, will be recorded. Some of this information will be provided to the Australian Government Department of Health who fund this program. Please note that identifying information such as your name and date of birth will not be passed on to the Department of Health.Your confidential information will be kept private by all health care professionals, including GP down south who are bound by the Commonwealth Privacy Act 1988, which outlines the principles concerning the protection of your personal information.

RECORD OF PATIENT CONSENTPlease indicate who is consenting to collection, use and disclosure of personal health information? Adult Patient Child / adolescent

(parent / guardian consent has not been sought)

Child / adolescent patient(parent / guardian consent has been sought)

PATIENT TO COMPLETEI agree to information about my mental health and wellbeing being collected, used and disclosed to the allied health provider I am referred to, to assist in the management of my health care.I am also aware that information (that will not identify me) is being collected and used to assist in the management of the ATAPS program, and I agree to this de-identified data being collected and shared.It is the responsibility of the patient to contact GP down south on 9754 3662, if the patient does not receive a letter of confirmation by

mail within 10 days of referral date.Patient Name: Patient Signature:

Parent Guardian Name: Parent Guardian Signature:

Date:

GENERAL PRACTITIONER TO COMPLETEI have discussed the proposed referral with the patient / parent / guardian, and I am satisfied that the patient / parent / guardian understands the proposed collection, use and disclosures of personal health information and has provided consent.I hereby notify GP down south that I have referred this patient to the ATAPS program for services as part of the Better Outcomes in Mental Health Care Initiative and have completed an assessment as the first step in the Mental Health Treatment Plan process.To the best of my knowledge, this patient is a Health Care Card holder or meets the criteria under Tier 2 (Perinatal Depression, Child under 12 with diagnosed Mental Health Condition, Homeless or at risk or is Aboriginal or Torres Strait Islander).GP Name: GP Signature:

Date:

Please provide a mental health care plan with this referral to GP down southCopy of this Referral Form is to be given to the Patient

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