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 - MANDATORY

All eligibility criteria must be met

Individual Income is less than $55,000 or family income is less than $130,000	<<Individual/Family Income - $55,000  to
$130,000>>	
The individual lives in the lives in the CESPHN area <<The individual lives in the CESPHN area>>	
If out of the CESPHN area, does the person work or study in area?
<<If out of area, does the person work or study in area>> Find your local PHN 	
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 for court or insurance>>	

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:Surn
ame>>	
Preferred Name:	<<Patient Demographics:Known
As>>	

Date of Birth:	<<Patient Demographics:DOB>
>	
Gender:	<<Patient
Demographics:Gen der>>	
Sexuality:	<<Patient
Demographics:Transg ender>>	

Country of Birth:	<<Patient Demographics:Coun try of Birth>>	
Aboriginal Torres Strait Islander:	<<Patient Demographics:ATSI>
>	Identifies as Culturally and Linguistically
Diverse (CALD):	<<Identifies as Culturally and Linguistically
Diverse>>	
English proficiency:	<<English proficiency:>>	Preferred Language:	<<Patient Demographics:Lang
uage Preferred>>	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 out of area, does the person work or study in 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:	<<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>>	
NOK Consent to contact	<<NOK Consent to contact>>	Emergency Consent to contact	<<Emergency Consent to contact>>	

Clinical Assessment

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 >>

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>>

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>>

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

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. Co-existing condition impacting mental health
<<4a. Co-existing condition impacting mental health>>

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>>

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. Performance pressure(work¥school) <<6a. Performance pressure(work/school) >>
6a. Grief and Loss <<6a. Grief and Loss>>
6a. Trauma (history/Current)	<<6a. Trauma (historic/current)>>
6a. Illness	<<6a. Illness>>
6a. Significant life transition	<<6a. Significant life transition >> 6a. Interpersonal difficulties	 <<6a. Interpersonal difficulties>> 6a. Risk of harm from others		<<6a. Risk of harm from others >> 6a. Legal¥financial issues	<<6a. Legal¥financial issues>>
6a. Difficulties in meeting psychosocial needs	<<6a. Difficulties in meeting psychosocial needs>>

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

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

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, would a headspace referral be appropriate?	<<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 or date
of birth>> >>	
Does the individual identify as transgender or gender diverse?	<<Identifies as transgender or gender
diverse?>>	

For 'Children' selection, please complete the below fields:
For Child PSS program selection, does the child have any learning, social or behavioural issues?	<<PSS Child - Learning social or
behavioural issues?>>	
For Child PSS program selection, does the child have any eating, sleeping or exercise related concerns?	<<PSS Child - Eating, sleeping or
exercise 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)>>	
Diagnosis - more information if applicable	<<Diagnosis - more
information 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's Goals>>	

Have you discussed the assessment, referral and treatment options with the individual?	<<Aware of assessment referral & treatment
options?>>	
Have you provided psychoeducation?	<<Have you provided
psychoeducation?>>	
Current services (please specify)	<<Please specify current
services>>	
Previous Treatment	<<Previous treatment>>	
Please specify previous treatment	<<Please specify previous
treatment>>	

If yes is selected for previous CESPHN commissioned services used, please specify	<<Specify previous CESPHN Commissioned
Services>>	
Any other relevant information?	<<Any other relevant
information?>>	
Outcome tool used	<<Outcome tool completed>>	Outcome tool score	<<Outcome tool score>>	
Client Medications	Client medication-Antipsychotics
<<Client medication-Antipsychotics>>	Client medication
- Anxiolytics
<<Client medication - Anxiolytics>>	Client medication - Hypnotics and Sedatives
<<Client medication - Hypnotics and
Sedatives>>	Client medication - Antidepressants
<<Client medication - Antidepressants>>	Client medication-Psychostimulants and Nootropics
<<Client medication-Psychostimulants
and Nootropics>>	

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 from past 12 months>>	

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/Ene rgy>>	
Attention/ Concentration	<<Attention/Conc entration>>	Judgement/ Insight	<<Judgement/Insigh t>>	Memory	<<Memory>>	
Speech	<<Speech>>	Orientation	<<Orientation>>			

PSS Mental Health Practitioner Request

Would you like to nominate a specific PSS Mental Health Practitioner? (Please provide any specific needs regarding travel, gender etc.)
<<Requested PSS Provider – Name of Provider>>
If not, a PSS Provider will be allocated based on location

If the 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 will 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:
I consent to telehealth services and have access to a device that has a secure internet connection
<<Access to device & consent to Telehealth service>>
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

<<To participating in the program>>

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
<<To share information to aid service delivery>>

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

<<To share information with government bodies>>

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

<<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