Please complete all details – incomplete referrals will be returned to the GP

REFERRAL DATE
REFERRING GP DETAILS
GP Name	Phone
Address	Fax
Town	Postcode
REFERRAL TYPE
Please Select	Choose an item.
ELIGIBILITY
Mental Health Treatment Plan:	Choose an item.
Is patient currently accessing other mental health services?	Choose an item.
Has patient received mental health services with a private provider under the Better Access initiative (Medicare) within this calendar year?	Choose an item.
Is the patient currently receiving Income Support from the Government or experiencing genuine financial hardship?	Choose an item.
Clinical Eligibility
Provisional Diagnosis	Choose an item.
Referred for	Choose an item.
How long has patient had current mental illness	Choose an item.
If patient’s condition is chronic, severe, or complex, they may not be eligible for Strong Minds
Suicide risk assessment	Choose an item.
Homicide risk assessment	Choose an item.
Strong Minds is not an urgent service – if risk is high, please consider referral to Community Mental Health service contact 1800 011 511 (24hrs)
Would patient benefit from short term intervention (6-12 sessions)	Choose an item.
If patient is likely to require longer term intervention, Strong Minds is not the most appropriate service for your patient at this time
PATIENT INFORMATION
Patient Name	DOB:
Address
Contact Number
Alternate contact person and contact number (if applicable):
Aboriginal & Torres Strait Islander Status	Choose an item.
Does patient consent to being contacted by on the number/s above?	Choose an item.
Does patient consent to a message (voicemail or SMS) being left on the above number/s?	Choose an item.
Gender	Choose an item.
Patient Lives Alone	Choose an item.
Main Language Spoken at Home:	Interpreter required	Choose an item.
How well does the person speak English	Choose an item.
Mobility, visual or hearing impairment?
I have discussed with the patient/carer, and have gained consent for this information to be given to Marathon Health for the purpose of facilitating this referral, receiving contact, and commencing treatment. Choose an item. GP Signature:____________________________________ Date: ______________________ Patient/Carer Signature:____________________________ Date:_______________________ To refer to Strong Mind Western, submit both the completed referral form and Mental Health Treatment Plan to the Strong Minds Intake team. GPs please continue to regularly monitor patients following referral. GP Mental Health Treatment Plan & Review GPs Completed Mental Health Skills Training Item 2700 (20 mins - <40 mins) Item 2701 (>40 mins) GPs with Medicare Registered Mental Health Skills Training Item 2715 20 mins - <40 mins) Item 2717 (>40 mins) MENTAL HEALTH ASSESSMENT Date: GP Name Address: Provider No: Phone: Patient Demographics Name: DOB: Address: Age: Home Phone: Mobile: Relevant Family History: Patient Agreement Obtained informed consent from patient to proceed with the GP Mental Health Care Plan Process: Choose an item. Presenting Issues: Relevant History Past Mental Health Issues: Other significant History: Psychotropic Medications: Benzodiazepines/Anxiolytics Choose an item. Phenothiazines/Tranquillisers Choose an item. Mood Stabilisers Choose an item. Antidepressants Choose an item. Nil Other Mental Status Examination Appearance and General Behaviour Mood Thinking Affect Perception Sleep Attention & concentration Motivation & Energy Memory Judgement Insight Anxiety Symptoms Orientation Speech Risk Assessment Suicidal ideation? Suicidal intent? Mild/Moderate? Mild/Moderate? If patient is at high risk they may not be suitable for Strong Minds– please contact 1800 011 511 (24hrs) for appropriate services Outcome tool used: E.g. K10, SDQ, DASS Score Result: Mental Health - Plan Formulation - Main Problem/Diagnosis: Goals Actions/Treatments: Referrals Other referral: E.g. Drug & Alcohol? Community Mental Health team? Crisis/Relapse Prevention Plan discussed: Was a copy of the plan offered to the patient? Mental Health – Review 1st Review Date: Patient Name DOB GP Outcome Tool Results on review: Review comments: (Progress on goals and actions outlined in GP Mental Health Care Plan) Other relevant Information:
Patient Referral - Information Sheet GP to print and provide to patient Strong Minds Western This project is funded by the Commonwealth Department of Health and facilitated via the Western NSW Primary Health Network and Marathon Health

Referral - Your GP has organised a referral following a Mental Health Treatment Plan. Referral information will be provided to the Marathon Health Strong Minds team.

Sessions – Up to 12 time-limited sessions (50 minutes) are available, via and mixture of Face to Face service and Tele Health. You will need to see your GP for a review of your Mental Health Treatment Plan after the initial six sessions if further sessions are required.

Who will contact you: You will be contacted by a member of the Marathon Health Strong Minds staff to discuss your referral and assess if Strong Minds is the right service for you. If your referral is accepted, you will be offered an appointment.

Access to Private Information - Your GP, the Marathon Health Strong Minds staff and your mental health provider will have access to your information.

De-identified data (information with no names, addresses or contact details) will be collected by Marathon Health Strong Minds staff and stored in a secure data base. This de-identified data will form part of the program reporting requirements for the WNSWPHN.

You can contact Marathon Health Strong Minds Western on (02) 6826 5271 if you have any questions about this service.

Strong Minds Western is not an urgent service and there may

be a wait time to access an initial appointment.

Please return to your GP, or see the contact numbers listed below

if you need additional support.

EMERGENCY NUMBERS
24 hr Mental Health Information and Support Service	1800 011 511
Kids Help Line	1800 55 1800
Lifeline	13 11 14
Parent Line	1300 130 052
Emergency Services	000