Referral Form and Mental Health Treatment Plan

Marathon Health ATAPS/MHSRRA Mental Health Programs

Referral Form and Mental Health Treatment Plan

Submit via secure fax: 02 6882 7224 or to

Please complete all details – incomplete referrals will be returned to the GP

REFERRAL DATE
REFERRING GP DETAILS
GP Name / Phone
Address / Fax
Town / Postcode
REFERRAL TYPE(not all programs available in all locations – please contact Marathon Health for program availability)
General ATAPS / MHSRRA / Aboriginal and Torres Strait Islander
Child under 12 yearsParent/carer name: / Perinatal Depression Due date: ______or has baby <12mths
Please tick: Initial Referral Review Re-Referral - approx. date patient last access ATAPS:
Preferred mental health provider / Next Available OR Name:
ELIGIBILITY
Financial Status: / Health Care Card holder
Low income earner / Genuine financial hardship
N/A – not eligible for ATAPS
Mental Health Treatment Plan: / Completed, signed and attached / N/A – not eligible for ATAPS
Is patient currently accessing other mental health services? / No / Unknown
Yes (describe):
Has patient received mental healthservices with a private provider under the Better Access initiative (Medicare) within this calendar year? / No
Yes – not eligible for ATAPS
CLINICAL ELIGIBILITY
Provisional Diagnosis: / Anxiety / Depression / Alcohol/Drug Use Disorder
Perinatal Depression / Childhood Behavioral Disorders (Children under 12 only)
Unknown / No Formal Diagnosis / Other: ______
Referred for: / Diagnostic Assessment / Cognitive Behavioural Therapy / Psycho-Education
Narrative Therapy / Interpersonal Therapy / Family Therapy (for PND/Children only)
Parent Training in Behaviour Management (Child referrals only) / Other: ______
Severity of presentation / Mild Moderate Severe / persistent
Risk assessment
ATAPS is not an urgent service – wait times may apply / Low – not urgent Moderate – not urgent
High Risk / acute / urgent – not eligible for ATAPS
Would patient benefit from short term intervention
(6-12 sessions) / Yes
No, patient requires long-term support - not eligible for ATAPS
If patient at high risk or severely unwell they may not be suitable for ATAPS – please contact 1800 011 511 (24 hrs) for appropriate services
PATIENT INFORMATION
Patient Name
Address
Contact Number
Alternate contact person and contact number (if applicable):
Does patient consent to being contacted by on the number/s above? / Yes No
Does patient consent to a message (voicemail or SMS) being left on the above number/s? / Yes No
Gender / Male / Female
Background / Aboriginal / Torres Strait Islander / Neither / Unknown
Patient Lives Alone / Yes / No / Unknown
Main Language Spoken at Home / English / Other (describe):
How well does the person speak English / Very Well Well Not Well Not At All Unknown
Highest Level of Education / Primary or Below Primary-Year 10 Year 10 Year 11 Year 12 Tertiary
I have discussed with the patient/carer, and have gained consent for this information to be given to Marathon Health for the purpose of facilitating this referral, receiving contact, and commencing treatment.
GP Signature:______/ Date: ______Date of next review: ______
Patient / Carer Signature:______/ Date: ______
Important Information for GPs:
To refer into ATAPS, submit BOTH the completed referral form and Mental Health Treatment Plan to the Marathon Health Centralised Intake teamvia: secure fax: 02 6882 7224 or
GPs should NOT send ATAPS referrals directly to Allied Health professionals - appointments should not be made until the ATAPS referral has been accepted by Marathon Health.
ATAPS is a capped service and wait lists may apply
GP Mental Health Care Assessment, Plan & Review
GPs Completed Mental Health Skills Training / Item 2700
(20 mins - <40 mins) / Item 2701
(>40 mins)
GPs with Medicare Registered Mental Health Skills Training / Item 2715
20 mins - <40 mins) / Item 2717
(>40 mins)

MENTAL HEALTH ASSESSMENT Date: ______

ADDRESS TO: Marathon Health Mental Health team – ATAPS/MHSRRA Referral and MHTP

GP Name: / Address:
Provider No: / Phone:
Patient Demographics / Please tick if patient details are same as details listed on Referral Form
Name: / DOB:
Address: / Age:
Home Phone: / Mobile:
Aboriginal/TSI?
Relevant Family History:
Patient Agreement
Obtained informed consent from patient: ______to proceed with the GP Mental Health Care Plan Process: Yes? No?
Presenting Issues:
Relevant History
Past Mental Health Issues:
Other significant History:
Psychotropic Medications:
Benzodiazepines/Anxiolytics / Phenothiazines/Tranquillisers
Mood Stabilisers / Antidepressants
Nil / Other
Mental Status Examination
Appearance and General Behaviour / Mood
(Depressed/Labile)
Thinking
(Content/Rate/Disturbances) / Affect
Flat/Blunted
Perception
(Hallucinations etc) / Sleep
(Initial Insomnia/Early morning wakening)
Cognition
(Level of consciousness/delirium/intelligence) / Appetite
(Disturbed Eating Patterns)
Attention & concentration / Motivation & Energy
Memory
(Short & long term) / Judgement
(Ability to make rational decisions)
Insight / Anxiety Symptoms
(Physical & Emotional)
Orientation
(Time/place/person) / Speech
(Volume/Rate/Content)
Risk Assessment
Suicidal ideation?
Mild/Moderate? / Suicidal intent?
Mild/Moderate?
If patient is at highrisk they may not be suitable for ATAPS – please contact 1800 011 511 (24hrs) for appropriate services
Outcome tool used: / Score Result:
Mental Health - Plan
Formulation - Main Problem/Diagnosis:
Goals / Actions/Treatments:
Referrals
Other referral: E.g. Drug & Alcohol? Community Mental Health team?
Crisis/Relapse Prevention Plan discussed:
Was a copy of the plan offered to the patient? / Yes? No?
Mental Health – Review

1st Review Date:

Patient Name
DOB
GP
Outcome Tool Results on review:
Review comments:
(Progress on goals and actions outlined in GP Mental Health Care Plan)
Other relevant Information:

2nd Review Date:

Exceptional Circumstances must apply

Patient Name
DOB
GP
Outcome Tool Results on review:
Review comments:
(Progress on goals and actions outlined in GP Mental Health Care Plan)
Describe the exceptional circumstances that apply:
Other relevant Information:

Please call the Marathon Health Mental Health team on 02 6826 5271 for more information or visit

Patient Referral - Information Sheet
GP to print and provide to patient
Access to Allied Psychological Services (ATAPS) and
Mental Health Services in Rural and Remote Areas (MHSRRA) programs
These projects are funded by the Commonwealth Department of Health and
facilitated via the Western NSW Primary Health Network and Marathon Health

Referral - Your GP has organised a referral following a mental health treatment plan. Referral information will be provided to the Marathon Health Mental Health Team.

Sessions – Up to 12 time-limited sessions (1 hour) are available, please see your GP for a review of your Mental Health Care Plan after 6 sessions, if further sessions are required

Who will contact you: You may be contacted by a member of the Marathon Health Mental Health team if any more information is required to facilitate your referral.

Once your referral has been processed by Marathon Health, an ATAPS mental health provider will contact you to arrange an appointment time

Access to Private Information - Your GP, the Marathon Health Mental Health Team and your mental health provider will have access to information that is able to be identified with you.

De-identified data (information with no names, addresses or contact details) will be collected by Marathon Health Mental Health staff and stored in a secure data base.

This de-identified data will form part of the project report to the Department of Health.

You can contact Marathon Health on (02) 6826 5271 if you have any questions about this service.

ATAPS is not an urgent service and there may

be a wait time to access an initial appointment.

Please return to your GP, or see the contact numbers listed below

if you need additional support.

EMERGENCY NUMBERS
24 hr Mental Health Information and Support Service / 1800 011 511
Kids Help Line / 1800 551 800
Life Line / 13 11 14
Parent Line / 1300 130 052
Emergency Services / 000

Date of next review with your GP: ______

Please call the Marathon Health Mental Health team on 02 6826 5271 for more information or visit