My Mental Health Services Referral
Secure electronic transfer to Ref:LP4030000BW or Fax: 07 3630 7839
                                                            Phone 1800 752 235 	
If acute mental health and/or risk of harm identified, please call 
Acute Care Team 1300 642 255 or ‘000’.

Information and resources are available at: https://brisbanenorthphn.org.au/our-programs/mental-health-services

Which program are you referring to?	 <Which Program are you referring to?>	
Preferred location for service	 <Preferred location for service>	
Date:	<TodaysDate>     	
Referrer Details	
Name:	<DrName>	GP Provider Number:	<DrProviderNo>    	
Practice:	<Practice>   	Phone:	<UsrPhone>    	
Email:	<PracEmail>  			
Client Details	
Name: RE:	<PtFullName>  	DOB:	<PtDoB>     	
Phone:	<PtPhoneH>  
<PtPhoneMob>   	Email:	<PtEmail>    	
Address::	 <PtAddress>   	Concession Card:	<Concession Card>	
Gender: 	<Gender>			
LGBTIQ:	<LGBTIQ>	Indigenous Status:	<Indigenous Status>	
Culturally and/or Linguistically Diverse:	<Culturally and/or Linguistically Diverse:>	Country of birth:	<Country of birth> 	
Preferred language:	<Preferred language>  	Proficiency in spoken English:	<Proficiency in spoken English:>	
Interpreter Required:	<Interpreter Required:>			
Consent: By consenting to this referral, the person is consenting to the sharing of their personal information. This information is held in a referral system repository by the Brisbane North PHN. The information contained in the referral is used by Brisbane North PHN to: (1) deliver care, (2) for monitoring, aggregate reporting and evaluation purposes to improve quality and access to care. Personal information is never shared or reported by any staff at Brisbane North PHN. This information will be passed on to the referral organisation who will contact the person unless requested otherwise.
Client Consent:  <Client Consent>	

Guardian/Carer/Parent Details	
Name:	<Guardian/Carer/Parent Details Name>     	Phone:	<Guardian/Carer/Parent Details Phone>  	
Email:	<Guardian/Carer/Parent Details Email>	Relationship to client:	<Guardian/Carer/Parent Relationship to Client:>	
Emergency contact details	
Name:	 <Emergency contact details Name>    	Phone:	<Emergency contact details phone>	
Relationship to client:	<Relationship to client:>	
Reason for Referral: <Reason For Referral>
	
Recent transition to parenthood?	Recent transition to parenthood?			
Are present symptoms related to a history of trauma?	<Present symptoms related to history of trauma?>	Detail the impact symptoms are having on daily functioning:	<Describe functioning iimpact of symptoms:>	
Assessment Areas
Brisbane North PHN utilises the Initial Assessment and Referral Guidance from the Department of Health to support referrers in determining the best level of care for a person.  For more information, a copy of the full guidance is available here: https://d1jydvs1x4rbvt.cloudfront.net/downloads/Mental-health-services/National-MH-IAR-Guidance-17Dec2019_V1.03-Accessible.pdf?mtime=20200707192013&focal=none 	
Symptom severity and distress:	<Symptom severity and distress:>	Diagnosis:	 <Diagnosis>    
	
Risk of harm:	<Risk of harm>	Risk to others:	<Risk to others>	
Suicidal ideation:	<Suicidal ideation>	Psychosis:	<Psychosis:>	
Self-injury:
Risk comments:	<Self-injury:>
<Risk comments>	Functioning:	<Functioning:>	
Impact of co-existing conditions: (including substance use/misuse, physical health, intellectual disability or cognitive impairment):	<Impact of co-existing conditions:>	Treatment and recovery history:	<Treatment and recovery history:>	
Social and environmental stressors:	<Social and environmental stressors>	Family and other supports:	<Family and other supports>	
Engagement and motivation:	<Engagement and motivation:>	Mental Health Treatment Plan:	<Mental Health Treatment Plan:>	
Further notes/info about Primary Assessment Domains: <Futher notes:>	

My Mental Health Service Referral V1.1 02.11.2023