Healthy Minds
Mental health services for vulnerable people
Referral Form & Treatment Plan
(MBS Items 2700, 2701, 2715, 2717)
Please note if referring a child who does not have a mental health diagnosis
the above item numbers cannot be claimed.
FAX To: 1300 853 248
Healthy Minds Referral Criteria (The client must meet one of these referral criteria to be eligible for Healthy Minds)
Severe Financial Distress
Health Care Card Holder
Priority Groups (Please indicate if the client belongs to one or more of the priority groups below)
Forced Adoption
Aboriginal/Torres Strait Islander
Child (up to 12 years)
Homeless, or at risk of becoming homeless
Impacted by extreme climatic events
Rural & remote
Culturally and Linguistically Diverse
Perinatal depression
Weeks
pregnant:
Weeks
post birth:
At Risk of Suicide/Self-Harming (low to moderate risk only)
Referral Details
REFERRING GP/Psychiatrist/Paediatrician
MENTAL HEALTH PROFESSIONAL (MHP) (Select one option)
GP Request (Select from Healthy Minds provider listing)
Name
Practice
MHP name
Phone
Primary Health Network to allocate
Fax
Referral Date
Preferred Location
Client Details
Client Name
Note: If under 15 years parental
consent is required
Date of Birth
Gender
Client Address
Postcode
Postal Address
Postcode
Client Telephone
Home
Work
Female
Mobile
Name of emergency contact
Phone
Does this client pose any risks to the provider’s safety?
Prior Mental Health Care
Male
No
NO
YES - Please Describe:
Yes
Health Care Card Number
Expiry Date
eHealth Patient IHI Number
Demographic Details
Aboriginal
Torres Strait Islander
Neither
Unknown
Cultural Background
Culturally/linguistically diverse. Country of birth:
Very Well
English Proficiency
Well
Not Well
Unknown
Other Language Spoken at Home:
Interpreter required?
Highest Education Level
Primary
Living Status
Lives Alone
Phone: 1300 137 237
Not at all
Year 10
Yes
Year 11
No
Year 12
Tertiary
Lives with others
Unknown
Unknown
www.ncphn.org.au
Healthy Minds
Mental health services for vulnerable people
Referral Form & Treatment Plan
(MBS Items 2700, 2701, 2715, 2717)
Please note if referring a child who does not have a mental health diagnosis
the above item numbers cannot be claimed.
FAX To: 1300 853 248
Mental Status Examination
Appearance & General Behaviour
Normal
Other:
Mood (Depressed, labile)
Normal
Other:
Thinking (Content, rate, disturbances)
Normal
Other:
Affect (Flat, blunted)
Normal
Other:
Perception (Hallucinations etc)
Normal
Other:
Sleep (Initial insomnia, early morning wakening)
Normal
Other:
Cognition (Level of consciousness, delirium, intelligence)
Normal
Other:
Appetite (Disturbed eating patterns)
Normal
Other:
Attention/Concentration
Normal
Other:
Motivation/Energy
Normal
Other:
Memory (Short & long term)
Normal
Other:
Judgment (Ability to make rational decisions)
Normal
Other:
Insight
Normal
Other:
Anxiety Symptoms (Physical & emotional)
Normal
Other:
Orientation (Time, place, person)
Normal
Other:
Speech (Volume, rate, content)
Normal
Other:
Outcome Tool & Score
K10 (Kessler 10)
DASS 21 (Depression Anxiety
Stress)
BDI (Beck Depression Index)
SDQ
(Strengths & Difficulties
Questionnaire)
Score
EPDS (Edinburgh Postnatal Depression Scale)
Score
Score
BAI (Beck Anxiety Index)
Score
Score
MSSI (Modified Scale for Suicidal Ideation)
Score
Score
SF12 (Short Form 12 Item Health Survey)
Score
Primary Diagnosis (ICD-10)
F1 Alcohol & Drug Use
F2 Psychotic Disorders
F3 Depression







Drug use disorders
Alcohol use disorders
F4 Anxiety Disorders

Generalised Anxiety

Panic Disorder

Phobic Disorder

Post Traumatic Stress Disorder

Adjustment Disorder
Dissociative (conversion) Disorder
Children (0-12 years)
Phone: 1300 137 237
Acute Psychotic Disorder
Chronic Psychotic Disorder
Schizophrenia (non acute)
F5 Unexplained Somatic
Complaints


Sleep problems
Chronic Fatigue
Perinatal
Suicidal/Self harm Risk
Other
 Sexual Disorders






Bereavement Disorder
Eating disorders
Behaviour management
Bipolar Disorder
Attention Deficit Disorder
Enuresis
Referral for assessment of learning difficulties, behavioural issues and/or at risk of developing a
mental illness
www.ncphn.org.au
Healthy Minds
Mental health services for vulnerable people
Referral Form & Treatment Plan
(MBS Items 2700, 2701, 2715, 2717)
Please note if referring a child who does not have a mental health diagnosis
the above item numbers cannot be claimed.
FAX To: 1300 853 248
Current Medication
Antidepressants (eg; SSRI’s, SNRI’s, TCA’s)
Benzodiazepines & Anxiolytics
Phenothiazines & major tranquillisers (eg; risperidone, olanzapine, chlorpromazine, haloperidol, clozapine)
Mood stabilisers (eg: lithium carbonate, sodium valproate, carbamazepine)
Other Psychotropic Medication:
No Medication
Client Assessment
Presenting Issues
(eg; grief, anxiety,
insomnia)
Client History
(Psychological, social,
biological, family
history, substance
abuse etc)
Other Relevant
Information
(eg; mental state,
suicidal ideation)
Risks &
Commorbities
Allergies
Other Care Plan
Others involved in
client’s care
No
Yes - Please state:
Name/profession
Phone
Name/profession
Phone
Name/profession
Phone
Client Treatment Plan
Client Issues/Diagnosis
Problem, client needs
Phone: 1300 137 237
Goal
Eg; mental health goals agreed by GP & client reduce symptoms, improve functioning
Treatment/Action
Eg; psychological, pharmacological
treatments, support services, referrals, family
engagement to support goals
www.ncphn.org.au
Healthy Minds
Mental health services for vulnerable people
Referral Form & Treatment Plan
(MBS Items 2700, 2701, 2715, 2717)
Please note if referring a child who does not have a mental health diagnosis
the above item numbers cannot be claimed.
FAX To: 1300 853 248
Treatment Strategies Requested
Diagnostic Assessment
Psycho-education
Cognitive Behaviour Therapy (CBT)
CBT Behavioural Intervention
CBT Relaxation Strategy
CBT Skills Training
Other CBT:
Narrative Therapy
Interpersonal Therapy
Family-based intervention
Attachment intervention
Parent Training in Behaviour
Management
Parent-Child Interaction Therapy
Other Strategies
Follow up Information
Crisis/Relapse Arrangements/Contacts
Copy of plan given to client
Yes
No
Plan discussed with client
Yes
No
Client education given
Yes
No
Review Date (1 to 6 months from plan date)
Client Consent
I understand that I am being referred to Healthy Minds to support my mental health concerns
I have received a copy of Healthy Minds – Program Information
I agree to information about my mental health being collected, and disclosed to the health professional/s to whom I am referred
and to North Coast Primary Health Network.
I agree to de-identified statistical information contained in this document being used by North Coast Primary Health Network for
the purposes of the Healthy Minds program and being provided to the Department of Health.
I understand that this referral is for short term, focused, psychological treatment (up to either 10 or 12 sessions) with an
accredited mental health practitioner.
Client name:
Parent/Guardian name
(where applicable)
Signature:
Date:
Signature:
Date:
Signature:
Date:
GP Signature
GP name:
Phone: 1300 137 237
www.ncphn.org.au