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Name
*
First
Last
GP Practice
*
Email
*
Name
*
First
Last
Email
Age
*
Reason for referral (eligibility criteria)
GP Treatment plan attached
Reason for referral (eligibility criteria)
A diagnosed mental health disorder (according to criteria defined in the Diagnostic and Statistical Manual of Mental health Disorders – IV Ed of the World Health Organisation/ Diagnostic and Management Guidelines for Mental Health Disorders in Primary Care: ICD-10 Chapter V Primary Care version)
The patient has been previously hospitalised for treatment for the mental health disorder, or are at risk of hospitalisation
The patient is expected to need long term management of the mental health disorder
The patient provides consent to services from a mental health nurse
A primary care based GP or psychiatrist maintains responsibility for the patient’s management
The mental health disorder significantly impacts the person’s social, personal and/or occupational function
Has the patient previously accessed the Mental Health Nurse Initiative Program?
*
Yes
No
MDS Client Key (if known)
Diagnosis
Risk factors
Recent suicide attempt
Harm to others
Substance abuse
Poor self-care
Homelessness / unstable accommodation
Risk of exploitation
Care of children
Other (please specify)
Further details
Risk assessment completed
*
Yes
No
Mental Health Issues
Sleep
Appetite / food intake
Depressed mood
Elevated mood
Hallucinations
Delusions
Other (please specify)
Further details
Checkboxes
*
As the referring medical practitioner I confirm:
Phone
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