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Mental Health Nurse Program Referral Form

- Step 1 of 2

Date of referral *

Referrer Details

Name *

First

Last

GP Practice *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Mobile

Fax

Email *

Patient Details

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Mobile

Email

Date of Birth *

Age *

Reason for referral (eligibility criteria)

GP Treatment plan attached

Date of GP Treatment plan

Attach GP Treatment Plan here

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

Date of risk assessment

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:

I am satisfied that the patient understands that by referring them to the MHNP their personal information will be provided to the MHNP provider, that the provider will make contact with them directly and that they have provided informed consent for this referral

Signature (Please upload)

Date *

Email

Contact Us

Phone: (03) 6228 3344

E-mail: admin@rftas.org.au

Postal Address: PO Box 3108, West Hobart 7000

Office Address: 76 Goulburn Street, Hobart 7000

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At Richmond Fellowship Tasmania, we believe that people can and do recover and that everyone has a right to feel a sense of wellbeing.
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