CESPHN Clinical Services 
Review 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.

Information provided will be used to assist selection of the service for the individual’s needs. 
Referral Date:  <TodaysDate>

Eligibility Criteria for PSS Program - MANDATORY	

All eligibility criteria must be met

The individual's income is less than $55,000 or family income is less than $130,000  <Individual Income is less than $55,000 or family income is less than $130,000>	
Live, work or study in the Central and Eastern Sydney region   <Live, work or study in the Central and Eastern Sydney region>   Find your local PHN	
If the individuals address is out of the CESPHN area, do they work or study in the CESPHN area?    <If the individuals address is out of the CESPHN area, do they work or study in the CESPHN area?>   	
Mild to moderate mental illness    <Mild to moderate mental illness>	
The individual does NOT need a crisis or specialist DV service   <Does NOT need a crisis or specialist DV service>	
The individual does NOT need support with court or insurance matters   <Does NOT need support with court or insurance matters>	

This form can be billed as a Mental Health Care Plan if all components are filled in satisfactorily	
GP MHTP - MBS items Review 2717 or Consultation 2713
Child referral - MBS Item: 36 (20+ mins) / MBS Item: 44 (40+ mins)
COVID-19 Telehealth MBS items:  Telehealth MBS Items 

GP Details	
GP name:	<DrName>	Position:	<UsrQualifications>	
Practice name:	<Practice>	Postcode:	<DrPostcode>	
Practice phone: 	<DrPhone>	Practice email:	<DrEmail>	

Individual's Details	
First Name:	<PtFirstName>	Surname:	<PtSurname>	Preferred Name:	<PtPrefName>	
Date of Birth:	<PtDoB>	Gender:	<GenderIdentity>	Sexuality: 	<PtSex>	
Country of birth:	<Country of Birth>	Aboriginal Torres and/or Strait Islander:	<PtEthnicity>	Identifies as Culturally and linguistically diverse (CALD):	<Identifies as Culturally and linguistically diverse>	
English proficiency:	<English proficiency>	Preferred language:	<Preferred language>	Interpreter required?	<Interpreter>	
Homelessness 	<Homelessness Flag?>	NDIS Participant?	<NDIS Participant?>	Health Care Card?	<Healthcare card?>	

Contact details	
Address:	<PtAddress>	
Phone 1:	<PtPhoneH>	Phone 2:	<PtPhoneMob>	
Email:	<PtEmail>	

Next of Kin	
Mandatory for all referrals
This includes parent/carer details if the individual is a Child and/or emergency contacts 
Next of Kin/Emergency Name:	<NOKName>	
Relationship	<NOKRelation>	
Phone	<NOKContact>	
NOK/Emergency Consent to contact	<NOK Consent to contact>	

Clinical Assessment	

1. Symptom severity and distress 
Consider the severity, duration, complexity, and distress resulting from the person's symptoms
A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000
<1. Symptom severity and distress - Consider the severity, duration, complexity, and distress resulting from the person's symptoms - A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000>

2. Risk of harm 
Consider the level of risk as it relates to the person's potential for harm to self or others
A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000
<2. Risk of harm - Consider the level of risk as it relates to the person's potential for harm to self or others - A rating of 4 should be referred to the Mental Health Access Line on 1800 011 511 or 000>

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. 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>

3. Functioning
Consider the person's ability to function in their daily duties and roles
<3. Functioning - Consider the person's ability to function in their daily duties and roles>

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

4a. Type of co-existing conditions
<4a. Type of co-existing conditions>

5. Treatment and recovery history
Consider the person's previous treatment history, current service use and response to past or current treatment
<5. Treatment and recovery history - Consider the person's previous treatment history, current service use and response to past or current treatment>

6. Social and environmental stressors
Consider how the person's environment is contributing to their mental health condition
<6. Social and environmental stressors>

6a. Social and environmental stressors types;
Select one or more from the following types of stressors
<6a. Social and environmental stressor types>

7. Family and other supports 
Consider the informal supports that are available and capable of contributing to recovery
<7. Family and other supports - Consider the informal supports that are available and capable of contributing to recovery>

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

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
<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>

PSS Referral	
Please select from the list of underserviced groups	<Please select from the list of underserviced groups>	

Clinical and treatment history - Review - MANDATORY	
 Please provide a description of the presenting/current issues (please include any changes to risk, medications, or plan)
 MANDATORY	<Please provide a description of the presenting/current issues (please include any changes to risk, medications, or plan)>	
Please provide a brief review of the individual's progress against the initial MHTP goals	<Please provide a brief review of the individual's progress against the initial MHTP goals>	
Details of any mental health related hospital admission in the last 12 months	<Details of any mental health related hospital admission in the last 12 months>	
I have offered further Psychoeducation to support the individual's mental health needs	<Further support of psychoeducation has been offered>	
Outline of the current crisis/safety plan (please specify)	<Outline of the current crisis plan>	
Agreed date for next MHTP review:	<Agreed date for next MHTP review:>	
Medications	<Medications>	
Any other relevant information?	 <Any other relevant information?>	
  Follow up Outcome Tool:	  <Outcome tool completed><Please specify Other outcome tool>	  Follow up score:	  <Outcome tool score>	

PSS Mental Health Practitioner Request	

Name of the current PSS Mental Health Practitioner: <Current PSS Provider Name:>
Additional Notes e.g. request a change or a note to the MHP: <Additional Notes e.g. request a change or a note to the MHP:> 

Consent - MANDATORY	

I understand referrals made to the non-acute Suicide Prevention Support (SPS) program will be allocated to a provider within 72 hours. (Referrals received after 12pm on Friday may not be allocated until the following Monday)
<I understand referrals made to the non-acute Suicide Prevention Support (SPS) Program will be allocated to a provider within 72 hours. (Referrals received after 12pm on Friday may not be allocated until the following Monday)>
Referrers must confirm that they have read out the following and that the individual understands and has given (informed) consent:  

• I consent to telehealth services and have access to a device that has a secure internet connection 
<I consent to telehealth services and have access to a device that has a secure internet connection>

•	I have consented to participate in the program as it has been described to me by my referrer, and to being contacted by the allocated Mental Health Professional to arrange an appointment
<I have consented to participate in the program as it has been described to me by my referrer, and to being contacted by the allocated Mental Health Professional to arrange an appointment> 
•	I have consented to my information being shared between the service provider and the funding body Central and Eastern Sydney PHN (CESPHN), in accordance with the Privacy Act 1988 
<I have consented to my information being shared between the service provider and the funding body Central and Eastern Sydney PHN (CESPHN), in accordance with the Privacy Act 1988>
 
•	I have consented to my de-identified information such as date of birth, gender, and types of service used, being shared with the Department of Health and Ministry of Health for mandatory reporting requirements 

<I have consented to my de-identified information such as date of birth, gender, and types of service used, being shared with the Department of Health and Ministry of Health for mandatory reporting requirements> 
 
•	I have consented to my de-identified information, including this referral form being shared with CESPHN for project evaluation and quality improvement purposes, and agrees to be offered an experience of service survey 
<I have consented to my de-identified information, including this referral form being shared with CESPHN for project evaluation and quality improvement purposes, and agrees to be offered an experience of service survey>

GP Signature:______________________________________           
Date: <Date signed>

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