Sydney North Health Network

SYDNEY NORTH HEALTH NETWORK

ATAPS PARENT/INFANT GROUP REFERRAL FORM

Please call the ATAPS Referral line on 1300 782 391

GP must complete ALL SECTIONS then together with a copy of the GP Child Treatment Plan FAX directly to ALLIED HEALTH PROFESSIONAL (AHP)

AHP must be an Sydney North Health Network (SNHN) approved ATAPS provider

Date GP Child Treatment Plan Completed / _ _/_ _/_ _ _ _
Patient Unique Identification Number (PIN): / Expiry Date :

ATAPS funding is streamed and allocated to specific programmes.It is acknowledged that it is not possible to complete the Mental Health Treatment Plan for an infant, therefore the questions asked will focus on the mother.

Item numbers remain the same, these being MBS Item 44 (40+ mins) and MBS Item 36 (20+mins).

Referring Practitioner / Practitioner Contact / Practice Name / Date of Referral
Name:
GP Providernumber: / Phone:
Fax:
Provisional Referral
(Other Professional) / ☐Emergency Department / ☐Psychiatrist / ☐Maternal Health Nurse
☐Early Childhood Educator / ☐Paediatrician / ☐Other……………………
Child’s relationship to primary contact:
Parent Profile
Parent Initials:
Date of Birth:
☐Male ☐ Female
Postcode:
☐Aboriginal
☐Torres Strait Islander
☐Unknown
☐CALD
State ……………………
☐Neither / Infant / Child Profile
Child Initials:
Date of Birth:
☐Male ☐ Female
Postcode:
☐Aboriginal
☐Torres Strait Islander
☐Unknown
☐CALD
State ……………………
☐Neither / Language Spoken at Home
☐English
☐Other Language
State ……………………..
Level of English
☐Communicates well
☐Basic Communication
☐No English
☐Unknown
Interpreter needed
☐Yes ☐No / Eligibility
☐Parent Unemployed / Financial need
☐Single Parent
☐CALD
☐Parent / Child has complex support needs
☐Parent has Centrelink Income Support
Parent Level of Education
☐Completed Primary
☐Completed Yr 10
☐Completed Yr 12
☐Tertiary / Parent ever received specialist mental health care before?
☐Yes ☐ No ☐Unknown
☐First ATAPS Referral
☐Re-referral to ATAPS
☐Referral for Group ATAPS
☐Exceptional Circumstances / Parent Primary Diagnosis
☐No Mental Health Problems
☐Antenatal Depression
Weeks Gestation ……………
☐Post Natal Depression
DOB of Child ………………..
☐Anxiety
☐Depression
☐Alcohol and Drug Use
☐Other (Please State)
…………………………………
………………………………… / Child has /at Risk for
☐Attachment
☐Adjustment
☐Anxiety
☐Behaviour Problems
☐Bereavement
☐Depressed Mood
☐Emotional Problems
☐Enuresis / Encopresis
☐Feeding Difficulties
☐Situational Factors
☐Sleep Difficulties
☐Somatoform
☐Tics
☐Withdrawn / Dissociative
☐Other
…………………………………
Child Level of Education (If applicable)
☐Early Childhood Centre
☐Year in Primary / Child ever received specialist mental health care before?
☐Yes ☐ No ☐Unknown
☐First ATAPS Referral
☐Re-referral to ATAPS
Score for Adult
☐K10 …………………….
☐DAS21 …………………….
☐EPDS ……………………
☐Other …………………….. / Medications / Referred For:
☐Individual Therapy
☐Parent / Child Therapy /
Group
☐Group Therapy
Can tick more than one / Referral To:
Individual AHP:
Phone:
Group AHP:
Phone:
Please state name and dose
Referred to Allied Health Professional for:
☐ Interpersonal Therapy / ☐ Group Therapy / ☐ Diagnostic Assessment
☐Attachment Intervention / ☐ Psycho-Education / ☐ Parent-Child Intervention
☐ Narrative Therapy / ☐ Family Based Intervention / ☐ Parent Training
☐ CBT
Parent First Name: / Parent Family Name: / Landline: / Contact Safety
☐No contact
☐Landline only
☐Mobile only
☐Mail only
☐Email only
Any safety risks to consider for home visit
☐ No Risks
☐ Location
☐ Potential Violence
☐ Unleashed Dogs
☐ No Mobile Reception
☐ Other ……………….…………….
………………………………
Child First Name: / Child Family Name: / Mobile:
Address / Presenting Issues:
Parenting Issues / Risk of Significant Harm
☐Carer Concern
☐ Domestic Violence
☐ Drug and Alcohol Issues
☐ Emotional Abuse of Child
☐ Family Breakdown
☐ Financial Stress
☐ Homelessness
☐ Mental Health Issues
☐ Neglect / ☐Parenting Issues
☐ Physical Abuse of Child
☐ Psychological Harm
☐ Relinquishing Care
☐ Runaway Child
☐ Sexual Abuse
☐ Parental Suicide Risk
☐ Young Parent
☐ Unborn Child / Has there been a ROSH assessment?
☐Yes ☐No
Request for Chapter 16A?
☐Yes ☐ No
Allied Health Professional to complete
Group Name: / Group Start Date:

I have read the patient information leaflet and I give consent for my clinical information and that of my child to be shared with the ATAPS mental health professional. I understand that the ATAPS Mental Health provider is required to obtain a computer generated unidentifiable code for statistical purposes by inputting Family Name, First Name, Date of Birth and Gender. This information will NOT be stored on the computer and is for generationof the code only.

I agree that de-identified information may be transferred to SNHN to be used for evaluation purposes only.

Signature:…………………………………………………………….

Date: ……………………………………………………………………

Primary Health Networks gratefully acknowledge the financial and other support from the Australian Government Department of Health.

Sydney North Health Network (ACN 605353 884)

Final Version 1 Updated: 30072015