ATAPS

Provisional referral form

The Access to Allied Psychological Services (ATAPS) program aims to provide evidence-based short-term psychological strategies to clients at risk of developing a mental disorder. ATAPS program includes the following priority groups: Adults, Child Mental Health Services (CMHS), Aboriginal and Torres Strait Islander (ATSI) and Suicide Prevention.

ATAPS Provisional referrals can be made by via the below professionals:

‘Provisional Referral’ can be submitted by – occupational therapists, social workers, psychologists, mental health nurses, ATSI health workers, school psychologist/counsellor, principals/deputy principals, directors from early childhood services and medical officers in non-government organisations

or

self-referral for Suicide Prevention and ATSI Clients.

Please note, a client with a provisional referral will need to provide ATAPS Triage with a Mental Health Care Treatment plan from a GP within two weeks of ‘Provisional Referral’. An allied health professional may not refer someone to themselves or to someone in the same practice.

Provisional Referral Assessment
Please select one priority group that this referral is forand include date of referral
Date Click here to enter text. / ☐ Adults / ☐ ATSI / ☐ Suicide Prevention / ☐ Children *
* Has the child’s legal guardian/ parent consented to this referral? ☐Yes. If ‘No’ referral can’t be accepted.
Referral eligibility checklist.
☐ Client assessed as having low to moderate suicide risk (high risk clients are not eligible)
If high risk of suicide, please refer immediately to Crisis Assessment Triage Team (CATT):
1800 682 288 (previously known as 1800 NTCATT) Free and confidential 24-hour hotline to qualified members of the Top End Mental Health Service who can provide support and link callers with appropriate services in their area of the NT.
Please note when client attends GP for ‘Referral’, GP will assess other eligibility criteria with them.
Client Details Confidential
Surname / Click here to enter text. / Telephone / Click here to enter text. /
Given name / Click here to enter text. / Date of birth / Click here to enter text.
Address / Click here to enter text. / Postcode / Click here to enter text. /
Language(s) Spoken at home / Click here to enter text. / How well does this client speak English / Well ☐ Not well ☐
Require translator ☐
Is this client Aboriginal and/or Torres Strait Islander / No ☐ Aboriginal ☐ Torres Strait Islander ☐ Both ☐ Unknown ☐
Next of kin/parent/legal guardian details
Surname / Click here to enter text. /
Given name / Click here to enter text. / Date of birth / Click here to enter text. /
Contact details / t Click here to enter text. / e Click here to enter text.
m Click here to enter text.
Address / Click here to enter text. / Postcode / Click here to enter text. /
Description of clients presenting concern(s)
Click here to enter text.
Client consents to GP liaising with ATAPS Triage service (client to sign and date below if they approve)
Signature: Date: Click here to enter text.
Referring source (must be completed if referral is sent by clinic/ organisation/company)
Name / Click here to enter text.
Clinic/ Organisation / Click here to enter text. / t Click here to enter text.
Email / Click here to enter text.
☐ I refer the client for individual therapy and have explained to the client that they are required to attend a GP appointment for a Referral within two (2) weeks of this Provisional Referral.
Date Click here to enter text.
☐Client has requested specific psychologist Click here to enter text.

Please send completed form to or fax to (08) 8944 2099

For further information contact CatholicCare NT on t 1800 899 855

You may be contacted by ATAPS Triage to provide further clarification if required

Health Network Northern Territory Ltd operating as Northern Territory PHN
We value: Relationships ● Equity ● Responsiveness ● Innovation ● Results
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