Forward completed Referral via Medical Objects to: Head to Health Gold Coast Referrals
or Fax 3186 4099

This referral form will be used by the Head to Health phone service. The consumer will be contacted for an assessment to determine the most appropriate service intensity and type.

This referral form replaces the previous GCPHN Mental Health Stepped Care Services Referral form.

If you have completed a MHTP or used the Initial Assessment and Referral Decision Support Tool please attach with the referral. 

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 Head to Health phone service to: (1) deliver assessment and referral 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 in this form has been discussed/provided to pt >>

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

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

REFERRAL DATE: <<Miscellaneous:Date (short)>> 

REFERRER DETAILS
Referrer's role	<<Referrer's Role>>	
Referrer's name	<<Doctor:Name>>	
Referrer's email	<<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:Sex>> 	Other gender identify (if applicable) <<Patient - other gender Identity (if applicable)>>	
Address  <<Patient Demographics:Full Address>>	Experiencing homelessness <<Experiencing homelessness>>	
Home phone number  <<Patient Demographics:Phone (Home)>> 	Mobile phone number  <<Patient Demographics:Phone (Mobile)>>	
Aboriginal &/or Torres Strait Islander status  <<Identifies as Aboriginal and/or Torres Strait Islander>>	Health Care/Pension Card  <<Health Care/Pension Card>>

Expiry date <<Health Care/Pension Card expiry date>>	
	Culturally or Linguistically Diverse (CALD)  <<Culturally or Linguistically Diverse (CALD)>>
Language spoken at home <<Language spoken at home>>
Is an interpreter required  <<Is an interpreter required>>	
Is there a current Mental Health Treatment Plan in place?  <<Is there a current MH 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>>	

RISK OF HARM
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 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.	
REFERRAL NOTES
Mental health diagnosis  <<Mental health diagnosis>>
	
Severity of current symptoms and associated level of distress  <<Symptom severity and associated level of distress>>
	
Medications

<<Clinical Details:Medication List>>
	
Treatment goals and hopes of the patient  

<<Treatment goals and hopes of the patient>>
	
Other services being accessed

<<What existing services are being accessed?>>
	
Please provide any additional information and/or identified needs to help inform assessment:

<<Referrer's Comments - additional info/needs>>

Please note: This referral form replaces the previous GCPHN Mental Health Stepped Care Services Referral form. You no longer need to select a service on this form as the consumer will be assessed by the Head to Health Phone Service to determine the best service for their needs.

The Head to Health Phone Service can assess and refer clients to GCPHN Mental Health Stepped Care services and other funded services. For more information about the GCPHN Mental Health Stepped Care Services, visit https://gcphn.org.au/wp-content/uploads/2023/05/GCPHN-Funded-Services-Mental-Health-7.pdf (copy url into browser).

Please be advised the new Supporting Minds Program commenced services in March 2023. This service contains a blend of clinical and non-clinical workers and could be a possible alternate service option for people who previously accessed the Psychological Services Program. GPs can make direct referral using the referral form at www.wmq.org.au/mental-health/supporting-minds (copy url into browser). Note: The Psychological Services Program (PSP) has now ceased.