PATIENT NAME:   <<Patient Demographics:Full Name>>                                        		DOB: <<Patient Demographics:DOB>>

MENTAL HEALTH SHARED CARE CHECKLIST
Date: <<Miscellaneous:Date>>
Action
	Frequency	Responsible	Date Completed	
Complete annual physical health check and copy results to MHS#
	Yearly	GP	£ __/__/__	
Review following ccCHiP* appointment
[May double as yearly physical health check]
	Ad hoc 	GP	£ __/__/__	
Complete scripts – physical health medications

	6 monthly	GP	When required	
Order/review other preventative screening e.g.: pap smears, mammograms, bowel screening, prostate check.
	Yearly	GP	When required	
Complete metabolic monitoring: Blood pressure, waist circumference and weight 
	3 monthly	MHS#	When required	
Complete scripts – mental health medications

	6 monthly	MHS	When required	
Complete ccCHiP referral
[GPs may refer directly to ccCHiP – referral form available on website: http://ccchip.clinic] 	Yearly 	MHS	£ __/__/__	
Organise GP review post ccCHiP attendance
	4 weeks post ccCHiP 	MHS	£ __/__/__	
Complete  pathology screen and copy results to GP
	Yearly
	MHS	£ __/__/__	
Complete lithium levels and copy results to GP+ 

	6 monthly	MHS	£ __/__/__
£ Not Applicable	
Complete routine cardiac screening (ECG/ echocardiogram) for patients prescribed clozapine and copy results to GP+	Yearly	MHS	£ __/__/__
£ Not Applicable	
*ccCHiP = COLLABORATIVE CENTRE FOR CARDIOMETABOLIC HEALTH IN PSYCHOSIS
#MHS = MENTAL HEALTH SERVICE
+ CONTINUE CURRENT ARRANGEMENTS WHERE GP IS PRESCRIBING &/OR MONITORING CLOZAPINE &/OR LITHIUM
All parties agree to:
•	NOTIFY EACH OTHER OF SIGNIFICANT CHANGES IN CONDITION/ TREATMENTS/ STAFF
•	EXCHANGE OF HEALTH SUMMARY INFORMATION ANNUALLY (OR AS AGREED). GP: HEALTH SUMMARY, TEAM CARE ARRANGEMENT; MHS: MENTAL HEALTH REVIEW
•	COPY PATHOLOGY RESULTS / SPECIALIST REFERRALS BETWEEN GP AND MHS	

GP NAME: <<Doctor:Name>>
<<Practice:Name>>, <<Practice:Address>>, Ph: <<Practice:Phone>> Fax: <<Practice:Fax>>