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: 	<<Miscellaneous:Date>>

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:	<<Doctor:Name>>	Position:	<<Referrer Position>>	
Practice name:	<<Practice:Name>>	Postcode: 		<<Doctor:Postcode>>	
Phone: 	<<Practice:Phone>>	Practice email: 	<<Practice:E-mail>>	

Individual's Details	
First Name	<<Patient Demographics:First Name>>	Surname:	<<Patient Demographics:Surname>>	Preferred Name:	<<Preferred name:>>	
Date of Birth:	<<Patient Demographics:DOB>>	Gender:	<<Patient Demographics:Gender>>	LGBTIQ:	<<LGBTIQ Status:>>	
Country of Birth:	<<Patient Demographics:Country of Birth>>	Aboriginal Torres Strait Islander:	<<Patient Demographics:ATSI>>	Identifies as CALD:	<<Identifies as CALD:>>	
English proficiency:	<<English proficiency:>>	Preferred Language:	<<Preferred Language:>>	Interpreter required?	<<Interpreter required?>>	
Homelessness flag:	<<Homelessness Flag>>	NDIS Participant?	<<NDIS Participant?>>	Health Care Card?	<<Health Care Card?>>	

Individual's 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>>	
If the individual's address is out of the CESPHN area, do they work or study in the CESPHN area?  <<If the individual's address is out of the CESPHN are>>  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:	<<Patient Demographics:Next of Kin>>	Emergency Contact Name:	<<Patient Demographics:Emergency Contact>>	
Relationship	<<Patient Demographics:Next of Kin Relationship>>	Relationship	<<Patient Demographics:Emergency Contact Relationship>>	
Phone	<<Patient Demographics:Next of Kin Phone>>	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
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 sev>>

2. Risk of harm
Consider the level of risk as it relates to the person's potential for harm to self or others
<<2. Risk of harm - Consider the level of risk as it relat>>

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
<<3. Consider the level of risk as it relates to the pers>>

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 con>>

4a. Impact of co-existing conditions
<<4a. 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
<<5. Treatment and recovery history - Consider the pe>>

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

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

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 >>

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

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>>

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?	<<If youth referral, can a Headspace referral be made>>	
For 'Perinatal' selection, select the baby's due date or date of birth	<<Perinatal - Due date of birth>>	

For 'Children' selection, please complete the below fields:
Does the child have any learning, social or behavioural issues?	<<Learning social or behavioural issues?>>	
Does the child have any eating, sleeping or exercise related concerns?	<<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>>	
Diagnosis	<<Client diagnosis>>	
Additional diagnosis (if applicable)	<<Additional diagnosis (If applicable)>>	
Presenting Issues - What are the current mental health issues? MANDATORY	<<Presenting issues>>	
Individual's Goal - What treatment is recommended and what is to be achieved by the treatment
MANDATORY	<<Individual Goals>>	
Have you discussed the assessment, referral and treatment options with the individual?	<<Client discussion >>	
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 previous treatment:>>	
Please specify which CESPHN Commissioned Services	<<Specify which CESPHN Commissioned Services>>	
Medication	<<Client medications>>	
Any other relevant information?	<<Any other relevant information?>>	
Outcome tool used:	<<Outcome tool used>>	Outcome tool score	<<Outcome tool score>>	

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

Mental State Examination - MANDATORY	
Appearance and Behaviour	<<Appearance and 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	<<Memory>>	
Speech	<<Speech>>	Orientation	<<Orientation>>			

PSS Mental Health Practitioner Request	
Would you like to nominate a specific PSS Mental Health Practitioner? 
<<Name of Provider - PSS MH Practitioner Request>>
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?

Consent to an alternate provider where required: <<Consent to an alternate provider where required?>>

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) <<Non-acute SPS Referral 72 hrs allocation timeframe>>
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>> 

•	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 share information to aid service delivery>> 

•	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 
•	<<To share information with government bodies>>

•	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
•	<<Share information and be contacted for evaluation >>

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