GP ADOLESCENT HEALTH ASSESSMENT
PATIENT DETAILS
Date:
Dear:
RE:
Thank you for agreeing to see
whom has is currently a patient of mine.
The reason for this referral is:
The following assessment has been completed with an initial mental health treatment plan developed:
Affirm attendance, Discuss confidentiality, Explain Medicare, Discuss billing policy, Ensure patient has provided consent,
Consider separate file from family, Consider time alone + time with caregiver
Patient Name
Assessment Date
DOB
Gender
Culture & language
/
/
GP
Other services/adults (eg. Parents, guardians, carers, agencies)
involved in patient care
PATIENT HISTORY- GENERAL
Health History & Selected Progress Notes
Clinical History:
Medications/ Immunisations
Drug Name:
Dose
Frequency
Route
Allergies
Family History
PATIENT PSYCHOSOCIAL ASSESSMENT
HEADSS FRAMEWORK
H – Home (Consider- living arrangements, transience, relationships with carers/significant others, community support,
supervision, abuse, childhood experiences, cultural identity, recent life events)
E – Education, Employment, Eating, Exercise (Consider- school/work retention & relationships, bullying,
study/ career progress & goals, nutrition, vegetarianism, eating patterns, weight gain/loss, exercise, fitness, energy)
A – Activities, Hobbies & Peer Relationships (Consider- hobbies, belonging to peer group, peer activities &
venues, lifestyle factors, risk-taking, injury avoidance, sun protection)
D – Drug Use (Consider- alcohol, cigarettes, caffeine, prescription/Illicit drugs and type, quantity, frequency,
administration, interactions, access, recent increases/decreases, past treatments, education, motivational interviewing)
S – Sexual Activity & Sexuality (Consider- sexual activity, age onset, safe sex practices, same sex
attraction, history pap smears/STI screening, sexual abuse, pregnancy/children)
S – Suicide, Depression & Mental Health, Safety/Risk (Consider- normal vs clinical depression, anxiety,
reactions to stress, if appropriate- depression scale, mental status exam, risk assessment, relapse plan)
K10 outcome tool & result (if appropriate):
Tool used:
Outcome score:
MENTAL STATUS EXAMINATION
Appearance and General
Behaviour
Thinking (Content / Rate /
Disturbances)
Perception (Hallucinations
etc)
Cognition (Level of
consciousness/ delirium /
intelligence)
Attention / Concentration
Mood Depressed / Labile
Memory (Short & Long term)
Judgment (Ability to make
rational decisions)
Anxiety Symptoms (Physical
& Emotional)
Speech (Volume / Rate /
Content)
Significant support person
Insight
Orientation (Time / place /
person)
Significant cultural factors
Affect Flat / Blunted
Sleep (Initial Insomnia / Early
Morning Wakening)
Appetite (Disturbed Eating
Patterns)
Motivation & Energy
RISK ASSESSMENT
(Consider risk to self-health, safety & development, risk to others, range and severity of risk factors, short & long-term risks,
escalation, knowledge & insight into risk & consequences, comorbidities, lifestyle factors, protective factors and behaviours)
Suicidal ideation
Suicidal intent
Current plan
Risk to Others
PHYSICAL ASSESSMENT DATA
(Consider- rapport, trust, consent- patient/parent as appropriate, normality, explanation, reassurance, cultural issues,
support person).
PATIENT MANAGEMENT PLAN
PROBLEM
DIAGNOSIS
ACTION
FOLLOW UP
Investigations/treatment (options/costs)
Referral information (costs/access)
Patient education provided
Follow up and recall arrangements
Other (consider the use of appropriate MBS items
such as EPC, Family Therapy, HMRs, SIPs and
BOIMH)
Preferred patient contact method & time
Completing the plan
 Has young person has been provided psycho-education / information:
 The young person agrees/consents to management plan?
 Copy of the Plan provided to the young person?
MENTAL HEALTH REFERRAL PIN NO:
REFERRAL EXPIRY DATE:
Statement of consent:
I give my consent for
information to be provided to the preferred provider outlined in this treatment
plan. I also consent for de-identified information to be provided to the intake / referral line to enable referral
approval.
Review date:
(initial review 4 weeks to 6 months after completion of plan)
GP signature:
Client signature:
Date:
Date: