Gold Coast Primary Health Network
Psychological Services Program
Exceptional Circumstances Referral Form 

Forward completed Exceptional Circumstances Referral Form via Medical Objects to: GCPHN Referrals
or to the PCCS Intake Team: Secure Fax  07 3186 4099
GPs, Paediatricians and Psychiatrists can call 07 3186 4000 for service information.

WHAT ARE EXCEPTIONAL CIRCUMSTANCES?
Exceptional Circumstances are defined as:
•	a significant change in the individual's clinical condition or care circumstance where ceasing treatment would lead to a detrimental outcome for the patient, which makes it appropriate and necessary to increase the maximum number of occasions of service, or 
•	where there is a clinical need for a patient to access a second or third block of suicide prevention sessions in one calendar year.
GPs, Paediatricians and Psychiatrists should be guided by their professional ethics and/or Code of Conduct to determine that the patient meets the above requirements.
HOW TO REFER UNDER EXCEPTIONAL CIRCUMSTANCES
Before completing this Exceptional Circumstances Referral Form, please refer to the Mental Health Professional's report outlining information on assessments, treatment provided, outcomes and recommendations on future management for the patient.
When completing the Exceptional Circumstances Referral Form consider whether the patient's significant change in clinical condition, care circumstances or reasons why ceasing treatment will lead to a detrimental outcome. Consider if any other treatment pathways are available for the patient.

Referral Date  <<Miscellaneous:Date (short)>> 
Patient Details
RE: <<Patient Demographics:Full Name>> 	DOB:  <<Patient Demographics:DOB>> 	
Address  <<Patient Demographics:Full Address>>		
Home Phone No  <<Patient Demographics:Phone (Home)>> 	Mobile Phone No  <<Patient Demographics:Phone (Mobile)>>	
A CURRENT Health Care/Pension Card is mandatory to access the Psychological Services Program.
It is not required for other PHN programs.	Health Care/Pension Card Number: <<Patient Demographics:Pension Number>>
Expiry date: <<Health Care/Pension Card expiry date>>	

Referrer Details
Referrer's Name	<<Doctor:Name>>	
Referrer's Email	<<Doctor:E-mail>>	
Provider Number	<<Doctor:Provider Number>>	
Practice Name	<<Practice:Name>>	
Practice Address	<<Practice:Address>>	
Practice Phone No	 <<Practice:Phone>>	
Practice Fax No	<<Practice:Fax>>	
Referrer's Signature		

Referral Details
Have you received and reviewed the report from the Mental Health Professional following the initial sessions?
YES OR NO (delete one)
*If No, please contact the Mental Health Professional for the report prior to making this referral. 

	
Have you considered a psychiatric review?
YES OR NO (delete one) 

If No, why is this not appropriate?  

	
Outline below the exceptional circumstances relevant for this referral - for suicide prevention referrals, please attach risk assessments undertaken by the GP/referrer to determine the need for further suicide prevention psychological sessions (If no risk assessment is attached this referral won't be accepted. This will delay the intake process for your client):

	
Have you discussed with the patient whether they would like to continue with the same Mental Health Professional or would like to change?
YES OR NO  (delete one) 

If the patient requests a change of Mental Health Professional, what is the identified reason?