Mental Health Services Helpline Referral
Phone: 1800 332 388
Fax: 03 6173 0306		
	Please Note:    
	Fax completed form to MHS helpline (available all hours) 03 6173 0306 with any appropriate reports. 
Any confidential or urgent issues can be notified by phone.
Clear writing and current contact details are appreciated to avoid delay in progressing this referral.	

	

Patient Details	
Referrer Details (or stamp)	

Name <PtFullName>    DOB <PtDoB>	
Name <DrName>	

Address <PtAddress>	
Address <Practice>
<DrAddress> 
<DrCity> <DrPostcode>	

Mobile <PtPhoneMob>	
Phone <DrPhone>	

Next of Kin <Next of Kin or Carer>    NOK/Carer <Next of Kin or Carer Phone>	
Fax <DrFax>	

Cultural Background <Cultural Background>   Preferred Language <Preferred Language if Other than English>	
Provider <DrProviderNo>

Indigenous or Torres Strait Islander <Indigenous or Torres Strait Islander>     Interpreter needed <Interpreter Needed>	
Length of referral 
q indefinite 
q other	

Signature	
Date <TodaysDate>	

PART A
1	Reason for Referral to Mental Health Services             þ Tick all boxes that apply	
a		Assessment and		Assessment and		Medication advice and		Assessment and suggestions		Other	
		MHS to Manage		co-management		continued GP Management		for GP to manage (specify below)			
	Additional information 
	
b	 Urgency		  Routine 			   Urgent (please indicate what risk factors make this referral urgent)  	
					  	
c	Presenting Problem	

	
d	Mental Health System Review	
	Sleep		Early Morning Awakening		Poor Sleep		No Sleep     Problem Duration			
	Appetite		Significant / weight loss		Mild Loss		Excessive/unhealthy weight gain			
	Energy									
	and Motivation		Lack of energy		Loss of Motivation		Mild anhedonia		Marked anhedonia	
	Mood		Abnormally low mood		Elevated mood		Irritability		Abnormal mood changes	
	Delusions and									
	hallucinations		Delusional ideas		Paranoia		Hallucinations		Command hallucinations	
	
Other important factors: 
	
	Mental Health History	
		
	Relevant Medical History	
	<SelectedPMH>	
	Social and Family History	
	<SocialHx>  <FamilyHx>	

	Current Medications	
	<SelectedRx>	

2	   Risk Factors								 þ Tick all boxes that apply	
			Current suicidal thoughts / expressed intent			Work at Risk	
			Harm to others			Patient has plans / means to attempt suicide	
			Alcohol and Drug use			Driving Risk	
			Care of Children			Other  (specify below)	
			Family at risk			
	
  Additional information 	

PART B - Children Under 18 Years
Please complete this section only when referring children under 18 Years
3	  Consent	
a	  Is this person able to consent as a mature minor?      q	Yes	q	No	
b	 Please provide the details of a parent / guardian who gives consent for the referral 	
		Name: 			
		Address:		
		Phone:												Post Code: 	
c	  Issues relevant to children	
		  Emotional		  Behavioural		  Family/Parental Issues		  Developmental		  Legal		  Physical	
d	  Other services involved or considered (please specify, e.g. Paediatrician, allied health, child protection, school counsellors, courts)	

PART C - Adults aged 65 +
Please complete this section only when referring adults aged 65 and over
4	  Older Persons							
a	  Does this person live alone?			Yes		No			
b	  Can they travel to an appointment?		Yes		No			
c	  Who is the initial contact person?		Self		Other 		(specify)  	
d	  Has this person been seen by ACAT or other services?		Yes		No		   Unsure	
e	  Details of ACAT or other services	
		
f	  Does this person have involved family or service supports?		Yes		No		
g	  Details of Family or Service Supports	
		
h	  Does this person have their medications supervised?			Yes		No		
i	  Does this person have a Webster pack?		Yes		No		
j	  Is there a MMSE score available?		Yes		No	  SCORE-  	

PART D - List Details of Attached Reports

<Ix>