Please complete all details – incomplete referrals will be returned to the GP
REFERRAL DATE	<TodaysDate>			
REFERRING GP DETAILS	
GP Name 	<DrFirstName><DrSurname>	Phone	<DrPhone>	
Address	<DrAddress>	Fax	<DrFax>	
Town	<DrCity>	Postcode	<DrPostcode>	
REFERRAL TYPE 	
Please Select	<Referral>	
ELIGIBILITY 	
Mental Health Treatment Plan:   	<MHTP>	
Is patient currently accessing other mental health services?	<Currently accessing services>	
Has patient received mental health services with a private provider under the Better Access initiative (Medicare) within this calendar year?	<Services with Better access or Private provider>	
Is the patient currently receiving Income Support from the Government?	<Income Support?>	
Clinical Eligibility	
Provisional Diagnosis	<Provisonal Diagnosis>		
Referred for	<Referred for>		
How long has patient had current mental illness	<How Long>		
If patients condition is chronic, severe, or complex, they may not be eligible for Strong Minds	
Suicide risk assessment	<Suicide Risk>		
Homicide risk assessment	<Homicide Risk>		
Strong Minds is not an Urgent Service – if risk is high, please consider referral to Community Mental Health service contact    1800 011 511 (24hrs)	
Would patient benefit from short term intervention 
(6-12 sessions)	<Benefit from Short term intervention>	
If patient is more likely to require longer term intervention, Strong Minds is not the most appropriate service for your patient at this time	
PATIENT INFORMATION	
Patient Name	<PtFullName><PtFullName>	DOB: <PtDoB>	
Address	<PtPOAddress><PtState><PtPostcode>	
Contact Number	<PtPhoneMob><PtPhoneMob><PtPhoneMob>	
Alternate contact person and contact number (if applicable):  	<NOKName><NOKContact><NOKName>	
Aboriginal & Torres Strait Islander Status	<Aboriginal & Torres Strait Islander status>	
Does patient consent to being contacted by on the number/s above? <Consent to contact>	
Does patient consent to a message (voicemail or SMS) being left on the above number/s?	<Consent to message>	
Gender	<Gender>	
Patient Lives Alone	<Lives Alone>		
Main Language Spoken at Home	                                                             Interpreter required	<Interpreter>	
How well does the person speak English	<English>	
Please advise your patient Strong Minds Western will be providing feedback to the referring GP regarding the outcome of this referral and any further recommendations or ongoing treatment. 	
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. Yes/No

GP Signature:____________________________________               Date: ______________________

Patient/Carer Signature:____________________________              Date:_______________________
To refer to Strong Mind Western, submit both the completed referral form and Mental Health Treatment Plan to the Strong Minds Intake team. GPs please continue to regularly monitor patients following referral.

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 – Strong Minds Referral and MHTP
GP Name: <DrFirstName><DrSurname>0	
Address: <DrAddress>00	

 Provider No:  <DrProviderNo>	
 Phone:   <DrPhone>	

Patient Demographics 	

Name:	
<PtFullName>	
DOB:	
<PtDoB>	

Address:	
<PtDetails>	
Age:	

Home Phone:	
<PtPhoneH>	
Mobile:	
<PtPhoneMob>	

Aboriginal/TSI? 	

Relevant Family History: 

Patient Agreement	

Obtained informed consent from patient to proceed with the GP Mental Health Care Plan Process:
 Choose an item.	

Presenting Issues:	

Relevant History	

	

Past Mental Health Issues:	

	

Other significant History:	

	

Psychotropic Medications:	

Benzodiazepines/Anxiolytics    	
<Medication>	
Phenothiazines/Tranquillisers    	
<Medication>	

Mood Stabilisers    	
<Medication>	
Antidepressants	
<Medication>	

Nil	
	
Other	

Mental Status Examination	

Appearance and General Behaviour	
	
Mood

Thinking	
	
Affect  	

Perception

Sleep

Attention & concentration	
	
Motivation & Energy	

Memory

Judgement

Insight	
	
Anxiety Symptoms

Orientation

Speech

Risk Assessment	

Suicidal ideation?

Mild/Moderate?	
	
Suicidal intent?

Mild/Moderate?	

If patient is at high risk  they may not be suitable for Strong Minds– please contact 1800 011 511 (24hrs) for appropriate services	

Outcome tool used: E.g. K10, SDQ, DASS 
	
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?	

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:	

Patient Referral - Information Sheet
GP to print and provide to patient 

Strong Minds Western
This project is 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 Strong Minds Team.

Sessions – Up to 12 time-limited sessions (50 minutes) are available, via and mixture of Face to Face service and Tele Health. You will need to see your GP for a review of your Mental Health Treatment Plan after the initial six sessions if further sessions are required.

Who will contact you: You will be contacted by a member of the Marathon Health Strong Minds staff to discuss your referral and assess if Strong Minds is the right service for you. If your referral is accepted, you will be offered an appointment. 

Access to Private Information - Your GP, the Marathon Health Strong Minds staff and your mental health provider will have access to your information.

De-identified data (information with no names, addresses or contact details) will be collected by Marathon Health Strong Minds staff and stored in a secure data base. This de-identified data will form part of the program reporting requirements for the WNSWPHN. 

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

Strong Minds Western 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	
Lifeline	13 11 14	
Parent Line	1300 130 052	
Emergency Services	000