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 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.  Info discussed pt

Patient or Parent/Guardian/Carer consents to Referral Patient Consent

Referrer consents to the collection and storage of referrer details on internal database  Referrer's Consent

Referral Date  Miscellaneous.Date

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

Referrer's role	Referrer's Role	
Referrer's name	Treating Doctor.Name	
Referrer's email	Treating Doctor.E-mail	
Practice name	Practice.Name	
Practice address	Practice.Address	
Practice phone no	Practice.Phone	
Practice fax no	Practice.Fax	

PATIENT DETAILS

RE: Patient Demographics.Full Name	DOB: Patient Demographics.DOB	
Gender  Patient Demographics.Gender	Other gender identity (if applicable)  Other Gender	
Address: Patient Demographics.Address	Experiencing homelessness Homelessness	
Home phone: Patient Demographics.Phone (Home)	Mobile phone: Patient Demographics.Phone (Mobile)	
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
Expiry date: Expiry date	
Aboriginal &/or Torres Strait Islander status  A&TSI	Culturally or Linguistically Diverse (CALD)  CALD
Language spoken at home  Language
Is an interpreter required  Interpreter	
Is there a current Mental Health Treatment Plan in place  MH Treatment Plan
Emergency contact name  EC Name	Emergency contact's relationship to person EC Relationship	
Emergency contact's phone number  EC Phone	Emergency contact's role  EC's Role	

CLINICAL INFORMATION

Mental health diagnosis  MH Diagnosis
	
Severity of current symptoms and associated level of distress  Symptom Severity
	
Kessler 10 score  K10
Kessler 5 Score (if referring to Kalwun Social Health Program): K5	
Family history of mental illness  Family history MH
	
Potential for harm to self or others  Potential for harm

Is the person currently self-harming  Self-harming
Is the person at increased risk of suicide  Suicide
Is this a referral for intensive suicide prevention support (8 sessions over 2 months)  Suicide prevention
Is there a risk of harm to others  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 very 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
	
Functional impairment caused or exacerbated by the mental health condition  Functional impairmen
	
Co-existing condition/s   Co-existing conditio

Impact of co-existing condition/s on severity of mental health condition or ability to participate in treatment  Condition severity
	
Treatment and recovery history  Treatment and recove

Initial Assessment Rating  T&R history - IAR
	
Social and environmental stressors  Soical and environme

Initial Assessment Rating  S&E - IAR
	
Family and other supports  Family and other sup

Initial Assessment Rating  F&OS - IAR
	
Engagement and motivation  Engagement and motiv

Initial Assessment Rating  E&M - IAR
	
Treatment goals and hopes of the patient  Goals and hopes
	
Medications 

Clinical Details.Medications - Current Regular
	
Existing mental health services being accessed  Existing MH services
	
Preferred provider gender  Provider gender
	
Psycho-education provided  Psycho-education
	
Mental Health Treatment Plan Review date (if applicable)  MHTP Review Date

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 below. Note, these services are not crisis services. More information about GCPHN funded services can be found on the GCPHN website - copy and paste the following link into your browser: https://gcphn.org.au/about/commissioning/gcphn-funded-services/

MENTAL HEALTH SERVICE RECOMMENDATION:  MH Service

Psychological Services Program Stream (if applicable)  PSP Stream
Preferred provider  Preferred Provider

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

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 of 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 	•	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 	•	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 Care

If postnatal, infant's DOB: Infant's  DOB	
High Intensity Mental Health 	•	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.