CESPHN Clinical Services Referral Form	

This is NOT A CRISIS Service.
If crisis support is required, call 000 or the Mental Health Access Line on 1800 011 511.

The information provided on this referral form will be used to assist you to select a service that is matched to your client’s needs. Please note, some services are restricted to people living in the Central and Eastern Sydney region. Services CESPHN commission are on our website.

Referral Date:					<<Miscellaneous:Date>>				1
Select the required service type: 		<<Service Type>>

This form can be billed as a Mental Health Care Plan if all components are filled in satisfactorily	
•	GP MHTP - MBS items 2700, 2701, 2712, 2713, 2715 and 2717
•	Child referral - MBS Item: 36 (20+ mins) / MBS Item: 44 (40+ mins)
•	Psychiatrist - MBS 291, the range 293-370
•	Consultant physician paediatricians - MBS 110 -133)	

Select the referral type: <<Select the referral type>>

GP Details	
Select ‘Yes’ if GP details are the same as Referrer details: <<GP same as Ref>>
GP name:	<<Doctor:Name>>	Position:	GP	
Practice name:	<<Practice:Name>>	Postcode: 		<<Doctor:Postcode>>	
Phone: 		<<Practice:Phone>>	Practice email: 	<<Practice:E-mail>>	
Fax:	<<Practice:Fax>>	Provider Number:	<<Doctor:Provider Number>>	

Client details	
Client First Name:	<<Patient Demographics:First Name>>	Client Surname:	<<Patient Demographics:Surname>>	
Preferred Name:	<<Client's preferred Name>>	Date of Birth:	<<Patient Demographics:DOB>>	
Gender:	<<Client gender>>	Marital status:	<<Patient Demographics:Marital Status>>	
Sexuality: 		<<Client sexuality>>	If other, please specify:	<<If 'Sexuality' differenty, please specify>>	
Country of birth:	<<Patient Demographics:Country of Birth>>	Preferred language:	<<Patient Demographics:Language Preferred>>	
Identifies as CALD:	<<Client identifies as CALD>>	Indigenous Status:	<<Patient Demographics:ATSI>>	
English proficiency:	<<Client's proficiency in english>>			
Interpreter required?	<<Is an interpreter required?>>	Interpreter language:	<<Please specify the interpreter language>>	

Is the client an NDIS Participant?	<<Is the client an NDIS participant?>>	
Does the client have a Healthcare Card? 	<<Does the client have a HealthCare Card?>>	
	
Client contact details	
Address:	<<Patient Demographics:Full Address Preferred>>	
		
Phone 1:	<<Patient Demographics:Phone (Home)>>	Phone 2:	<<Patient Demographics:Phone (Mobile)>>	
Email:	<<Patient Demographics:E-mail>>	

Next of Kin	

Please include parent/carer details if the client is a Child and/or emergency contacts	
Name:	<<Patient Demographics:Next of Kin>>	
Relationship to client:	<<Patient Demographics:Next of Kin Relationship>>	
Phone:	<<Patient Demographics:Next of Kin Phone>>	
Name:	<<Patient Demographics:Emergency Contact Phone>>	
Relationship to client:	<<Patient Demographics:Emergency Contact Relationship>>	
Phone:	<<Patient Demographics:Emergency Contact Phone>>	

Clinical Assessment	

1. Symptom severity and distress 
Consider the severity, duration, complexity, and distress resulting from the person's symptoms
0 = No descriptors below apply
1 = Some (but not all) symptoms of anxiety or depressive disorder, and/or mild distress for <6 months
2 = Symptoms indicative of anxiety/depressive disorder for >6 months and/or mod-high distress
3 = Significant ongoing mental health symptoms resulting in very high distress or recent hospitalisation
4 = Significant and persistent symptoms which are poorly managed and are with significant complexity 
A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000
<<1. Symptom/s severity and distress>>

2. Risk of harm
Consider the level of risk as it relates to the person's potential for harm to self or others
0 = No below descriptors apply
1 = Past ideation, no current or past risk of harm to self or others
2 = Current Suicidal ideation, without plan or intent. But may have had intent, plans or attempts in the past unrelated to current episode or current life stressors.
3 = Current suicidal ideation with intent and history of suicidal attempts; no plan or strong reluctance to carry out plan, strong protective factors, and a commitment to engage in a safety plan including involvement of family, significant others and services
4 = Current suicidal intention with plan and means to carry out. Few or no protective factors 
A Rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000
<<2. Potential level of risk of harm>>

2a. Consider the level of risk as it relates to the person's potential for harm to self or others including domestic violence, aggression and forensic
<<2a. Client's risk of harm>>

3. Functioning
Consider the person's ability to function in their daily duties and roles
0 = No descriptors apply
1 = Diminished ability to function in roles without adverse consequences
2 = Functioning in roles is impaired to the extent that they are unable to meet the role requirements
3 = Significant difficulties with everyday functioning resulting in disruption to many areas of life
4 = Profound difficulties with everyday functioning resulting in disruption to virtually all areas of life
<<3. Client's ability to function in daily duties>>

4. Co-existing Conditions
Are there co-existing conditions impacting on mental health or ability to participate in treatment?
<<4. Client co-exiting conditions>>

4a. Impact of co-existing conditions
0 = No co-existing conditions are present
1 = Co-existing conditions may be present but have limited impact
2 = Co-existing conditions may be present and are impacting significantly
3 = Co-existing conditions pose a threat to health or are seriously impacting
4 = Co-existing condition is severe, poorly managed, life-threatening and impacts significantly
<<4. Impact of co-existing Impact>>

5. Treatment and recovery history
Consider the person's previous treatment history, current service use and response to past or current treatment
0 = No prior treatment history
1 = Full recovery with previous treatment
2 = Moderate recovery with previous treatment
3 = Minor recovery with previous or current treatment and previous limited response to specialist support
4 = Negligible recovery with recent or current treatment and ongoing need for specialist support
<<Treatment and recovery history>>

6. Social and environmental stressors
Consider how the person's environment is contributing to their mental health condition
<<Social Environmental stress level>>
6a. Select one or more from the following types of stressors
<<Stressor type>>

7. Family and other supports
Consider the informal supports that are available and capable of contributing to recovery
0 = Substantial and useful supports are available, capable and willing
1 = A few useful supports are available, capable or willing
2 = Sources of support are reluctant or unable to provide consistent support
3 = Very few actual or potential sources of support available
4 = No useful supports are available
<<Family and other supports>>

7a. Please list the most useful supports available to the person
<<Please list useful supports>>

8. Engagement and motivation
Consider if the person understands their mental health condition, capacity to manage their condition and their willingness/motivation to participate in treatment
0 = Complete understanding of condition; active/motivated management; accesses supports
1 = Good understanding of condition; capable of active management; mostly willing to access support
2 = Limited understanding and interest in taking an active role; needs encouragement
3 = No ability or interest in managing condition; reluctance to accept supports
4 = No awareness; active avoidance of managing condition or accessing supports
<<Engagement and Motivation>>

If 'Mental Health Services PSS' is selected for Service Type, please respond to the PSS Eligibility Criteria below. For other Service Types, please proceed below.

Eligibility Criteria for PSS Program	
If 'Mental Health Services - PSS' was selected for Program Service Type, please respond to the PSS Eligibility Criteria below.  For PSS Eligibility, ALL eligibility criteria must be met. 
PSS is for people who may benefit from short term treatment, are unable to Access other available services including Better Access (Medicare subsidised psychological services) due to financial hardship.

Does the client meet the income threshold criteria for PSS (Individual Income is less than $55,000 or family income is less than $130,000)?	<<Does the client meet the PSS income threshold?>>	
The individual lives, works or goes to school in the Central and Eastern Sydney region	<<PSS - The client lives/works in the CES region>>	
The individual is experiencing mild to moderate mental illness, or severe mental illness and would benefit from short term psychological intervention	<<PSS - Mild to moderate mental health illness>>	
The individual is not better suited to a crisis or specialist domestic violence services and is not involved in court or insurance matters	<<PSS -  is not better suited to crisis/DV services>>	

All non -acute Suicide Prevention referrals received after 12pm on Friday afternoon may not be allocated till the following Monday. Please contact the Mental Health Line 1800 011 511 should your client require crisis support

Underserviced Groups	
Please select from the list of underserviced groups	<<Please select from the list of underserviced groups>>	
Is this a Group Referral?	<<Is this a group referral?>>	
If Group Referral, select the group session type	<<Group Session Type>>	
Is the individual client currently a PSS Client?	<<Is the client currently conected with PSS?>>	
If a PSS client, select the PSS group	<<PSS group name>>	
For 'Young Person' selection, can the client be referred to Headspace?	<<If Youth referral, can a Headspace referral be made>>	
For 'Perinatal' selection, select the baby's due date	<<Perinatal - Due date of birth>>	

For 'Aged Resident' selection, please complete the below fields
Name of the aged care facility	<<Name of aged care facility >>	
Does the client have dementia?	<<Aged care - Dementia>>	
Does the client currently have delirium?	<<Aged care - Delirium>>	
If the client has had an MMSE, what was the score?	<<Aged care - MMSE score>>	

For 'Children' selection, please complete the below fields
Does the child have any learning issues? 	<<Does the child have any learning issues?>>	
Does the child have any social or behavioural issues? 	<<Does the child have social or behavioural issues?>>	
Does the child have any eating, sleeping or exercise-related concerns? 	<<Child: Eating, sleeping or exercise related concern?>>	

Are you a Medical Practitioner?	<<Are you a medical practitioner?>>	
Are you billing an MHTP?
For child referrals please consider billing item numbers 36 or 44 	<<Are you billing an MHTP?>>	
Are you a Non-Medical Practitioner?	<<Are you a Non-Medical Practitioner?>>	

Mental State Examination	

Appearance and Behaviour	<<Appearance and Behaviour>>
Affect			<<Affect>>
Sleep			<<Sleep>>
Appetite			<<Appetite>>
Motivation/Energy		<<Motivation/Energy>>
Judgement/Insight		<<Judgement/Insight>>
Speech			<<Speech>>
Mood			<<Mood>>
Thinking			<<Thinking>>
Perception			<<Perception>> 
Andehonia			<<Anhedonia>>
Attention/Concentration		<<Attention/Concentration>>
Memory			<<Memory>>
Orientation			<<Orientation>>

PSS Mental Health Practitioner Request	
Is this client currently engaged with or have a history with a PSS mental health Practitioner that they would like to continue with, OR would you like to refer to a specific practitioner?
<<Name of Provider - PSS MH Practitioner Request>>
<<Would the client like a specific practitioner?>>

If not, a PSS provider will be allocated based on location
If preferred Mental Health Practitioner is not available do you consent for a alternative provider to be allocated?
<<Consent to an alternate provider where required?>>

Individuals Goal - What treatment is recommended and what should be achieved by the treatment
<<Individual goals>>

Crisis/Relapse	

Arrangements for crisis intervention and/or relapse prevention plan
Has the client had any hospitalisations?	<<Has the individual had any hospitalisations?>>	
If yes, how many hospitalisations has the client had in the last 2 years? (Mental or physical health)	<<Number of hospitalisations>>	
What was the length of stay per admission?	<<What was the length of stay per admission>>	
Is the client experiencing homelessness?	<<Is the client homeless or at risk of homelessness?>>	
Previous Treatment	<<Previous treatment>>	
Current Services	<<Current Services>>	

Client Health	

Client Diagnosis	<<Client Diagnosis>>	
Additional diagnosis	<<Additional diagnosis>>	
Have you discussed the assessment, referral and treatment options with the patient?	<<Client discussion >>	
Have you provided pscyho-education?	<<Have you provided psycho education?>>	
Client Medication	<<Client medications>>	
Outcome tool used:	<<Outcome tool used>>	Outcome Tool Score:	<<Outcome tool score>>	

Client Consent	
Referrers must confirm that they have read out the following and that the client understands and has given verbal consent:
•	to the program as it has been described to you by your referrer 
•	to your information being shared between the service provider and the funding body Central and Eastern Sydney PHN (CESPHN), in accordance with the Privacy Act 1988
•	to being contacted by the allocated Mental Health Professional to arrange an appointment
•	to being contacted by the service provider, CESPHN or its representative to complete a client experience of service survey
	<<Verbal consent given - see Page 7>>
In addition:
•	The client agrees to have their de-identified information, including this referral form being shared with CESPHN for project evaluation and quality improvement purposes  

•	The client agrees to have their de-identified information such as date of birth, gender, and types of service used, being shared with the Department of Health for mandatory reporting requirements. (If No was selected, the client’s data would be excluded).

I understand referrals made to the non-acute SPS program be allocated to a provider within 72 hours. The Mental  Health Line 1800 011 511 may be contacted for clients who require crisis support <<72 hours allocation timerame>>

Agreed date for review: 4 weeks to 6 months after initial MHTP:	<<Miscellaneous:Date>>

GP Signature:______________________________________		Date: <<Miscellaneous:Date>>

For more information on all Mental Health programs in the Central and Eastern Sydney region, visit www.cesphn.org.au