Adelaide Primary Mental Health Care Sevices (PMHCS)
Mental Health Treatment plan 
Item 2715/2717/2701/2700

Please note these details MUST be provided before the Mental Health Treatment Plan will be accepted by the PMHCS Central Referral Team for allocation to a service provider: Patient details, GP Details, Problem, diagnosis, Risk Assessment, Patient Consent and GP signature 

Step 1: Patient Assessment
Patient Details (must complete)
Name:	
<<Patient Demographics:Full Name>>	Outcome Tool Results:
K10/DASS (please circle)	<Outcome Tool Results - K10/DASS>	
Address:	<<Patient Demographics:Full Address>>	Phone Number:	<<Patient Demographics:Phone (Home)>>
<<Patient Demographics:Phone (Mobile)>>	
DOB:	<<Patient Demographics:DOB>>	Gender:	<<Patient Demographics:Gender>>	
Referral Date:	<<Miscellaneous:Date>>	Medicare No#	<<Patient Demographics:Medicare Number>>	
Does the patient identify as Aboriginal or Torres Strait Islander?	     << identify as Aboriginal or Torres Strait Islander>>	
Is the patient from a Culturally and Linguistically Diverse background?	<<Is the patient from a CALD background >>	
Does the patient have a My Health Record?	<<Does the patient have a My Health Record >>
<<Patient Demographics:IHI>>	

Patient Demographics 
Has the patient ever received specialist mental health care?  <<Has patient ever received specialist MH services>>	
Language spoken at home:    <<Patient Demographics:Language Spoken>>
How well does the patient speak English:   <<How well does the patient speak English>>
Does the patient require an interpreter: <<Patient Demographics:Requires Interpreter>>	
Does the patient live alone: <<Does the patient live alone>> If no, with whom___________________
Is the accommodation:  <<Is the accomodation>>	
Country of birth: <<Patient Demographics:Country of Birth>>      Nationality:  <<Nationality>>	
Employment Status:  <<Employment Status >>	
Pension or Health Card Status:  <<Pension or Health Care Card Status>>	
Marital Status:  <<Patient Demographics:Marital Status>>	
Does the patient have any dependents:  <<Does the patient have any dependents>>	
Psychosocial assessment: (e.g. childhood, substance abuse, relationship history, coping with previous stressors)	
<<Psychosocial assessment: >>	
 Eligibility Criteria for Primary Mental Health Care Services -  
<< Eligibility Criteria Primary Mental Health Care Ser. >>	
Mental Status Examination:	
Appearance and General Behaviour: <<Mental Status Appearance and General Behaviour >>	Mood (Depressed/Labile)  <<Mental Status - Mood (Depressed/Labile) >>	
Thinking (Content/Rate/Disturbances) <<Mental StatusThinking(Content Rate/Disturbances)>>	Affect (Flat/Blunted)  <<Mental Status - Affect (Flat/Blunted)  >>	
Perception (Hallucinations etc.) <<Mental Status - Perception (Hallucinations etc.) >>	Sleep (initial Insomnia/Early Morning Wakening) <<Mental Status Sleep (initial Insomnia/Early Morning)>>	
Cognition (level of Consciousness/Delirium/Intelligence) - <<Mental Status - Cognition (consciousness etc.)>>	Appetite (Disturbed Eating Patterns) <<Mental Status - Appetite (Disturbed Eating Patterns)>>	
Attention/Concerntation: <<Mental Status - Attention/Concerntation:>>	Motivation/Energy <<Mental Status - Motivation/Energy>>     	
Memory (Short and Long Term)  <<Mental Status - Memory (Short and Long Term)>> 	Judgement (ability to make rational decisions) <<Mental Status - Judgement>>	
Insight: <<Mental Status - Insight>>	Anxiety Symptoms (Physical & Emotional)  <<Mental Status -  Anxiety(Physical & Emotional) >>	
Orientation (Time/Place/Person) <<Mental Status - Orientation (Time/Place/Person)>>	Speech (Volume/Rate/Content) <<Mental Status - Speech (Volume/Rate/Content) >>	
Other Mental Health Professionals involved in patient care	
Name/Profession:	Contact number:	

GP Details
Name:	<<Doctor:Name>>	Practice Name:	<<Practice:Name>>	
Address:	<<Practice:Address>>	Phone:	<<Practice:Fax>>	
Presenting Problem/ Provisional Diagnosis (must complete)
Number 1	Number 2	Number 3	
<<Presenting Problem/Provisional Diagnosis No. 1  >>	<<Presenting Problem/ Provisional Diagnosis No.2>>	<<Presenting Problem/ Provisional Diagnosis No. 3>>	
Risk Assessment (must complete)
Suicidal ideation:	 <<Suicidal ideation (must Complete)>>	Suicide intent	 <<Suicide intent (must complete)>>	
Current suicidal plan:	<<Current suicidal plan (must complete)>>	Risk to others	<<Risk to others (must complete)>>	
GUIDE TO ABOVE RISK ASSESMENT OUTCOME: 
If YES to one or more of the above Risk Assesment questions please contact your local service provider.
If NO to the above Risk Assesment Clinical Triage will determine the service provider based on information supplied in this referral.	
Other Comments 

Medications:  <<Clinical Details:Medication List>>

	Allergies: <<Clinical Details:Allergies/Adverse Reactions>>	
Relevant physical and mental examination:  <<Relevant physical and mental examination >>	

Patient history
Include relevant biological, psychological and social history including any family history of mental disorders and any relevant substance abuse or physical health problems. 	
<<Summary:Progress Notes (Selected)>>
<<Clinical Details:Family History>>
<<Clinical Details:History List>>
<<Clinical Details:Social History>>

Step 2: Mental Health Care Plan
Key family contact/support details/phone:	
  <<Key family contact/support details/phone:>>	
Emergency Care/relapse prevention:	
<<Emergency Care/relapse prevention:>>

	
Initial action plan:	
GOAL	TREATMENT	REFERRALS	
<<Initial action plan - GOAL>>	<<Initial action plan -TREATMENT>>	<<Initial action plan - REFERRALS >>

	
Review date: (Add a recall in clinical software for 3-4 months after the Plan date)   	<<Review date: Add recall in software for 3-4 Months>>	
Copy of Mental Health Treatment Plan given to Patient: 	<<Copy of MH Treatment Plan given to pati>>	
Patient Consent to release information (must complete)	
I,<<Patient Demographics:Full Name>> (patient name-please print clearly) understand that this MHTP is being used as a referral for the provision of mental health services. This process involves an assessment and the development of a plan for treatment. I agree to be part of the process with the knowledge that:
•	My medical history will be shared with the GP and Clinician of the service chosen/and personnel of the chosen service where relevant;
•	The information collected is private and will be kept confidential unless agreed upon by all parties to be shared;
•	My GP has explained to me the reasons for seeking counselling/therapeutic input;
•	No Medico Legal Reports will be provided;
•	I understand that my treatment will be monitored and communicated between my treatment team.  
•	All personal information gathered will remain confidential and secure with my treating team and within the clinical management system hosted by the funding body APHN 
Therefore, in complying with the principles governing provision of this service we seek your consent. 
Patient signature________________________             Date: <<Miscellaneous:Date>>
GP Signature____________________________            Date: <<Miscellaneous:Date>>
For patients under 16 years:
Carer name:_____________________________           Carer signature___________________

PLEASE FAX YOUR COMPLETED REFERRAL FORM TO THE PMHCS CENTRAL REFERRAL TEAM ON: 1300 580 249