PHN-Funded Mental Health
Stepped Care Services	

Forward completed Referral via Medical Objects to: GCPHN Referrals
or Fax 07 3186 4099

This referral form will be used by the Mental Health Triage Service (07 3186 4000). Note, this form complies with Mental Health Treatment Plan requirements for billing items 2700/2701 or 2715/2717.

By consenting to this referral, the person is consenting to the sharing of their personal information. The information contained in the referral is used by the Mental Health Triage Service to: (1) deliver intake services, (2) for monitoring, aggregate reporting and evaluation purposes to improve quality and access to care. This information will be passed on to the recommended provider who will contact the person.

Please indicate the information in this form has been discussed with, and provided to, the patient.  <Indicate this info has been discussed and provided to patient>

Patient or Parent/Guardian/Carer consents to Referral  <Patient or Parent/Guardian/Carer consents to referral>

Referrer consents to the collection and storage of referrer details on internal database  <Referrer consents to collection and storage of referrer details on internal database>

Referral Date  <TodaysDate>

REFERRER DETAILS (must be a GP, Paediatrician or Private Psychiatrist)

Referrer's role	<Referrer's role>	
Referrer's name	<DrName>	
Referrer's email	<DrEmail>	
Practice name	<Practice>	
Practice address	<UsrAddress>	
Practice phone no	<UsrPhone>	
Practice fax no	<UsrFax>	

PATIENT DETAILS	

All information below is critical to support the triage and intake process. Please complete all fields.

RE:  <PtDetails>  	DOB: <PtDoB>  	
Gender  <PtSex>	Other gender identity (if applicable)  <Patient - Other Gender Identity (if applicable)>	
Address   <PtAddress>	Experiencing homelessness  <Experiencing homelessness>	
Home phone no  <PtPhoneH>  	Mobile phone no  <PtPhoneMob>	
A CURRENT Health Care/Pension Card is mandatory to access the Psychological Services Program (exceptions: suicide prevention, homelessness and children in out of home care).
It is not required for other PHN programs.	Health Care/Pension Card:  <Health Care/Pension Card>

Expiry date: <Health Care/Pension Card expiry date>	
Aboriginal &/or Torres Strait Islander Status  <Does the person identify as Aboriginal &/or TSI>	Culturally or Linguistically Diverse (CALD)  <Culturally or Linguistically Diverse (CALD)>
Language spoken at home  <Language spoken at home> 
Interpreter required  <Is an interpreter required>	
Is there a current Mental Health Treatment Plan in place  <Is there a current Mental Health Treatment Plan in place>	
Emergency contact name  <Emergency Contact Name>	Relationship to person  <Emergency Contact - Relationship to person>	
Phone number  <Emergency Contact Phone Number>	Role of emergency contact  <Role of Emergency Contact>	

CLINICAL INFORMATION

Mental health diagnosis  <Mental Health Diagnosis>

Severity of current symptoms and associated level of distress  <Severity of current symptoms and associated level of distress>

Kessler 10 Score  <Kessler 10 score>
Kessler 5 Score (if referring to Kalwun Social Health Program)  <Kessler 5 score (if referring to Kalwun Social Health Program)>

Family history of mental illness  <Family History of Mental Illness>

Potential for harm to self or others  <Potential for harm to self or others>

Is the person currently self-harming  <Is the person currently self-harming>

Is the person at increased risk of suicide  <Is the person at increased risk of suicide>

Is this a referral for intensive suicide prevention support (8 sessions over 2 months)  <Is this a referral for intensive suicide prevention support (8 sessions over 2 months)>

Is there a risk of harm to others  <Is there a risk of harm to others>

*If yes, please provide details of action taken and attach risk assessment.

**Please note this is not a crisis service. If assessed at high risk of harm, please contact Emergency Services on 000 or Acute Care Team on 1300 642 255.

Crisis Intervention and/or Relapse Prevention Plan  

<Crisis intervention and/or relapse prevention plan>

Functional impairment caused or exacerbated by the mental health condition  <Functional impairment caused or exacerbated by Mental Health condition>

Impact of co-existing conditions (e.g. chronic disease; substance use, cognitive impairment, etc)

Co-existing condition/s  <Co-existing condition/s, e.g. chronic disease, substance use, etc>

Impact of co-existing condition/s on severity of mental health condition or ability to participate in treatment  <Impact of co-existing conditon/s on severity of Mental Health condition or ability to participate in treatment>

Treatment and recovery history <Treatment and recovery history>
Initial Assessment Rating <Treatment and recovery history - initial assessment rating>

Social and environmental stressors <Social and environmental stressors>
Initial Assessment Rating <Social and environmental stressors - initial assessment rating>

Family and other supports <Family and other supports>
Initial Assessment Rating <Family and other supports - initial assessment rating>

Engagement and motivation <Engagement and motivation>
Initial Assessment Rating <Engagement and motivation - initial assessment rating>

Treatment goals and hopes of the patient

<Treatment goals and hopes of the patient>

Medications

<CurrentRx>

Other services being accessed  <What existing services are being accessed?>

Preferred provider gender (if appliable) <Preferred Provider Gender (if applicable)>

Psycho-education provided  <Psycho-education provided>

Mental Health Treatment Plan Review date (if applicable)  <Mental Health Treatment Plan review date (if applicable)>

MENTAL HEALTH STEPPED CARE SERVICES FUNDED BY GCPHN

The Mental Health Triage Service (07 3186 4000) will determine which service is most suitable along the stepped care continuum unless pre-selected by the referrer. Note, these services are not crisis services. More information about GCPHN funded services can be found on the GCPHN website. 

MENTAL HEALTH SERVICE RECOMMENDATION  <Mental Health SERVICE RECOMMENDATION (please select)>
If Psychological Services Program (PSP) selected above, please select stream  <If Psychological Services Program selected above, please select stream>
Preferred PSP provider (if applicable): <Preferred Psychological Services Program Provider (if applicable)>

Referrer's comments:  <Referrer's Comments>

SERVICE NEED	SERVICES AVAILABLE	SERVICE DESCRIPTION	
Aboriginal and/or Torres Strait Islander Mental Health / AOD / Suicide Prevention	• Case Management and Clinical Care Coordination - Kalwun Social Health

 	Kalwun Social Health is a low to high intensity service offering case management and clinical care coordination to individuals who identify as Aboriginal and/or Torres Strait Islander or partners, parents, or carers of, who are struggling with their mental health, alcohol and other drug misuse, or seeking a suicide support service.	
Moderate to High Intensity Youth Mental Health Services	•	Youth Psychosocial Support (12-25 LGBTIQAP+)

•	headspace (12-25)

•	headspace Early Psychosis (12-25)

•	Youth Clinical Care Coordination (12-18) - Lighthouse Program

	Expanded Horizons provides a group-based program for Lesbian, Gay, Bisexual, Trans, Intersex, Asexual, Pansexual or other diverse identities (LGBTIQAP+) young people or youth questioning sexuality or gender identify.

headspace is an accessible 'one-stop-shop' for young people aged between 12 and 25 which supports early intervention services for young people with emerging mental health needs. The service helps promote wellbeing: mental health, physical health, work/study support and alcohol and other drug services.

headspace Early Psychosis is a multidisciplinary service of consultant psychiatrists, peer workers and clinicians that support young people aged 12-25 at risk or experiencing a first episode of psychosis. The Early Psychosis team is equipped to intervene early to improve the lives of young people, and their families, who are impacted by psychosis.

Lighthouse Program provides trauma informed, recovery-orientated clinical care coordination and specialised treatment services for young people aged 12-18 years with severe and/or complex mental health needs.	
Low Intensity Mental Health Services	•	 Structured Psychological Therapy Services - Coaching Program

•	 Web-based Services: Head to Health Online Portal

	NewAccess is a mental health coaching program, designed to provide accessible, quality services for anyone finding it hard to manage life stress. People can access six coaching sessions delivered over the phone, via Skype or in person by trained mental health coaches. 

The Head to Health portal brings together apps, online programs, online forums, and phone services, as well as a range of digital information resources and is provided by the Australian Department of Health.	
Moderate intensity Mental Health Services	• Psychological Services Program

	The Psychological Services Program (PSP) offers short-term structured psychological therapies delivered by a range of providers contracted by the GCPHN. This program supports people who would benefit from receiving short term therapy and is not suitable for people that may need longer term and more comprehensive interventions. A CURRENT Health Care/Pension Card is mandatory to access the Psychological Services Program (exceptions: suicide prevention, homelessness and children in out of home care).

The program is available for people who identify with any of the following groups:

• Suicide Prevention*
• LGBTIQAP+
• Perinatal - Postnatal (Infant must be up to 1 year of age to be eligible)
• Children (0-12 years)
• Children in out of home care (0-12 years)*
• Aboriginal and/or Torres Strait Islanders
• Culturally and Linguistically Diverse Population (CALD)
• Homelessness*

*does not require Health Care/Pension Card

If Postnatal, infant's DOB: <If Postnatal, provide infant's DOB>	
High Intensity Mental Health Services	• Clinical Care Coordination - Plus Social

• Psychosocial Support

 	Plus Social Clinical Care Coordination is a comprehensive, high intensity clinical support service for people who experience the impact of severe mental illness and are not currently case managed or accessing Gold Coast Health mental health services.

Up to 26 weeks clinical care coordination and wellbeing program that is structured, recovery and goal orientated focused on creating significant improvements in quality of life, health and wellbeing. For ages 18+.

Psychosocial Support is a moderate intensity service which provides practical assistance and personalised support to people experiencing the impacts of significant mental health needs and who would like assistance with their recovery journey.