CESPHN Clinical Services 
Initial 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	

All eligibility criteria must be met
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? Find your local PHN	
Mild to moderate mental illness.  	
The individual does NOT need a crisis or specialist DV service.  	
The individual does NOT need support with court or insurance matters.	
The individual meets ALL the above criteria <The individual meets ALL the above criteria>	

This form can be billed as a Mental Health Treatment 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)
COVID-19 Telehealth MBS items: Telehealth MBS Items

GP Details	
GP name:	<DrName>	Position:	<Referrer Position>	
Practice name:	<Practice>	Postcode:	<DrPostcode>	
Practice phone: 	<PracEmail>	Practice email:	<PracEmail>	

Individual's Details	
First Name:	<PtFirstName>	Surname:	<PtSurname>	Preferred Name:	<PtPrefName>	
Date of Birth:	<PtDoB>	Gender:	<PtSex>	LGBTIQ: 	<LGBTIQ Status>	
Country of birth:	<Country of Birth>	Aboriginal Torres Strait Islander:	<Aboriginal Torres Strait Islander>	Identifies as CALD:	<CALD Status>	
English proficiency:	<English proficiency>	Preferred language:	<Preferred language>	Interpreter required?	<Interpreter>	
Homelessness Flag?	<Homelessness Flag?>	NDIS Participant?	<NDIS Participant?>	Health Care Card?	<Healthcare card?>	

Individual's Contact details	
Address:	<PtAddress>	
Phone 1:	<PtPhoneH>	Phone 2:	<PtPhoneMob>	
Email:	<PtEmail>	
If the individual's 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?>  Find your local PHN	

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 Name:	<NOKName>	Emergency Contact Name:	<Emergency Name:>	
Relationship	<NOKRelation>	Relationship	<Emergency relationship>	
Phone	<NOKContact>	Phone	<Emergency phone>	

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

4a. Impact of co-existing conditions<4a. Impact 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 stressors>

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>	
If Group Referral, enter the name of the PSS Group	<If Group Referral, enter the name of the PSS Group>	
For 'Young Person' selection, can a headspace referral be made?	<For 'Young Person' selection, can a headspace referral be made?>	
For 'Perinatal' selection, select the baby's due date or date of birth	<For 'Perinatal' selection, select the baby's due date or date of birth>	

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

Clinical and treatment history - MANDATORY	
 Agreed date for MHTP review: 4 weeks to 6 months after initial MHTP	<Agreed date for MHTP review: 4 weeks to 6 months after initial MHTP>	
 Diagnosis	<Initial Diagnosis>	
Additional diagnosis (if applicable)	<Additional Diagnosis (if applicable)>	
Presenting Issues - What are the current mental health issues? MANDATORY	<Presenting Issues - What are the current mental health issues? MANDATORY>	
Individual's Goal - What treatment is recommended and what is to be achieved by the treatment
MANDATORY	<Individuals Goal - What treatment is recommended and what is to be achieved by the treatment - MANDATORY>	
Have you discussed the assessment, referral and treatment options with the individual?	<Have you discussed the assessment, referral and treatment options?>	
Have you provided psychoeducation?	<Have you provided psychoeducation?>	
Current Services (please specify)	<Current services><Please specify current services>	
Previous Treatment 	<Previous Treatment><Please specify previous treatment:><Please specify which CESPHN Commissioned Services:>	
Please specifcy previous treatment	<Please specificy previous treatment>	
Please specify which CESPHN Commissioned Services		
Medication	<Medications>	
Any other relevant information?	<Any other relevant information?>	
 Outcome tool used:	  <Outcome tool completed>	 Outcome tool score:	 <Outcome tool score>	

Crisis/Safety Relapse Plan 	
Please provide an outline of the crisis/safety plan
MANDATORY	<Please provide an outline of the crisis/safety plan>	
Please provide details of any mental health related hospital admission in the last 12 months	<Please provide details of any mental health related hospital admission in the last 12 months>	

Mental State Examination  -  MANDATORY	
Appearance/ Behaviour	<Appearance/ Behaviour>	Mood	<Mood>	Affect	<Affect>	
Thinking		<Thinking>	Sleep	<Sleep>	Perception	<Perception>	
Appetite	<Appetite>	Anhedonia	<Anhedonia>	Motivation/ Energy	<Motivation/ Energy>	
Attention/ Concentration	<Attention/ Concentration>	Judgement/ Insight	<Judgement/ Insight>	Memory	<MSE Memory>	
Speech	<Speech>	Orientation	<Orientation>			

PSS Mental Health Practitioner Request	

Would you like to nominate a specific PSS Mental Health Practitioner? 
<Preferred provider Name: (Please include any specific needs regarding travel, gender etc.)>
If not, a PSS provider will be allocated based on location

If preferred Mental Health Practitioner is not available, do you consent for an alternative provider to be allocated? <If preferred Mental Health Practitioner is not available, do you consent for an alternative provider to be allocated?>

Consent - MANDATORY	

I understand referrals made to the non-acute Suicide Prevention Support (SPS) program 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 be allocated to a provider within 72 hours. (Referrals received after 12pm on Friday may not be allocated till the following Monday)>
Referrers must confirm that they have read out the following and that the individual understands and has given (informed)  verbal consent:  
•	To participating in the program as it has been described to you by your referrer, and to being contacted by the allocated Mental Health Professional to arrange an appointment 
•	<To participating in the program as it has been described to you by your referrer, and to being contacted by the allocated Mental Health Professional to arrange an appointment>
 
•	To individual's 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 individual's information being shared between the service provider and the funding body Central and Eastern Sydney PHN (CESPHN), in accordance with the Privacy Act 1988>
 
•	The individual 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 and Ministry of Health for mandatory reporting requirements 
•	<The individual 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 and Ministry of Health for mandatory reporting requirements>
 
•	The individual agrees to have their 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 
•	<The individual agrees to have their 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: <TodaysDate>
For more information on all Mental Health programs in the Central and Eastern Sydney region, visit www.cesphn.org.au