REQUEST FOR MENTAL HEALTH SERVICES							

GP Referral
		Referral Date: <TodaysDate>

Feedback Requested:  Yes	

Referral to: Barwon Health

Service requested: <Service Requested:>

Urgency:  <Urgency>
Referral vaid for:  <Referral valid for>		Referring General Practitioner:
<DrName> 
<Practice>
<PracHPIO>
<DrAddress> 
Email:<DrEmail>
Provider No.: <DrProviderNo>
HPI: <DrHPII>

Consumer details:
Name:	<PtFirstName> <PtSurname>
Date of Birth:	<PtDoB>
Age:                        <PtAge>
Preferred Name/s:	<PtPrefName>
Sex:	<PtSex>
Ethnicity:                <PtEthnicity>
Title:	<PtTitle>
IHI:                          <PtIHI>

Patient has been made subject of a Compulsory Assessment Order:
<Has the pt been made the subject of a compulsory Ax Order?>		Contact Address:	<PtName>
	<PtStreet>
	<PtCity>  <PtState>    <PtPostcode>
Phone:	<PtPhoneH>
Work:	<PtPhoneWk>
Mobile:	<PtPhoneMob>
Email:	<PtEmail>

Alternative Contact: 
<Alternative Contact (Name/Ph/Relationship)>
Next of Kin:
<Next of Kin (Name/Ph/Relationship)>
Legal status:
<Legal Status>

Interpreter required: <Does the patient require an interpreter?>		DVA Number: <PtDVANo>	
Preferred language is: <If interpreter needed, which language>		Insurance: <PtHealthIns>	
Pension Card Number: <PtPensionNo>		Medicare Number: <PtMCNo>	

Date patient consented to referral:  <FormattedDate>	
Consent to share information:  <Consent to share information>	
Patient consents to MBS bulk billing clinic if available:  <Consent to MBS bulk billing clinic>	

Westvic HealthPathways provides guidance in patient assessment, management and referral. 
<WestVic HealthPathways provides guidance in Ax, Mx & referral> 	

Patient: <PtFullName>,  DoB: <PtDoB> 

Reason for patient referral:

<Reason for Referral>
Functional Status:
Mental Health Care Plan undertaken:  <Mental Health Care Plan undertaken?>
MMSE:  <Has a MMSE been conducted?>  

Living arrangements:  <Living arrangements?>  
Accommodation setting:  <Accommodation setting?>
Current case management details:  
<Current case management details?>
Recent specialist or service referrals:  
<Recent specialist or service referrals>
Recent hospital admissions:
<Recent hospital admissions?>

 
Current Medication:
<RegularRx>
Allergies: <Reactions> 
Warnings: <Comment>	

Past Medical History: 
<PMHAll>
Social History:
<SocialHx> 
If smoker, smoking cessation discussed:  <If smoker, smoking cessation discussed?>	

Progress Notes: 
<Visits>	

Investigation Results:
<Ix>

GP Referral:  <DrName>,  Date of Referral:<TodaysDate>         Patient: <PtName>,  DoB: <PtDoB>