Next Step Referral Form
Please note, we are not a crisis service, if crisis assistance is required, please call Access Mental Health on 02 6205 1065 or emergency on 000
REFERRAL DETAILS
Referrer source:*
GP
Psychiatrist
Paediatrician
Other (please specify below)
Other, please specify:
Referrer Name:*
Practice Name:*
Contact details:*
Referral Information:*
Client MHTP emailed through to nextstepintake@mccg.org.au (required for GP referral)
Referral letter emailed through to nextstepintake@mccg.org.au (required for psychiatrist and paediatrician)
Referral will not be processed until a MHTP for client received by Next Step Intake team.
NEXT STEP SERVICES & ELIGIBILITY
(Please refer to Exclusion Criteria on CHN website)
Please consider for;
CBT based psychological interventions: (6- 18 targeted individual sessions with a CBT trained professional)
Adult Individual CBT (26 years +)
Youth Individual CBT (12- 25 yrs) *please note for mild to moderate presentations for 12-16-years please refer to Headspace
Child (under 12 yrs) - Cool Little Kids or Cool Kids Group evidence based 10-week group to build strategies to manage anxiety and associated behaviours
Child (under 12 yrs) - Individual psychological intervention 6- 16 sessions
Eligibility - must meet all of the following:
Live, work and/or study in the ACT:*
Yes
Unable to access Medicare psychological services (Better Access) due to financial and or other constraints:*
Yes
Currently not accessing other psychological interventions (excluding drug & alcohol or pain mgmt. services):*
Yes
Not better suited to a crisis, specialist or domestic violence service:*
Yes
Mental Health Treatment Plan completed and emailed through to Next Step intake team:*
Yes
PATIENT INFORMATION
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First Name:*
Last Name:*
Preferred Name:
Gender:*
Male
Female
Other
Date of Birth:*
Address Line 1:*
Town/City:*
Postcode:*
Contact Number:*
Email Address:*
Main Language Spoken:*
Please Select A Value...
Afrikaans
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Catalan
Celtic, nec
Chinese, nec
Creole
Danish
Dinka
Dutch
English
Estonian
Ethiopian
Farsi (Persian)
Finnish and Related Languages, nec
Flemish
French
French creole
Frisian
Gaelic (Scotland)
German
Greek
Gujarati
Hakka
Hausa
Hebrew
Hindi
Icelandic
Igbo (Ibo)
Indonesian
Irish
Italian
Japanese
Korean
Kurdish
Letzeburgish
Lingala
Luganda
Makaton (sign language)
Malayalam
Maltese
Mandarin
Nepali
Norwegian
Pashto (Pushtoo)
Patois
Persian
Polish
Portuguese
Punjabi
Russian
Scandinavian
Serbian/Croatian
Sinhala
Slovene
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Taiwanese
Tamil
Telugu
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yiddish
Yoruba
Other
Interpreter Required:
Yes
No
Proficiency in English:*
Please Select A Value...
Not applicable (persons under 5 years of age or who speak only English)
Very well
Well
Not well
Not at all
Not stated/inadequately described
Marital status:*
Please Select A Value...
Never married
Married (registered and de facto)
Separated
Divorced
Widowed
CARER/GUARDIAN INFORMATION (if applicable)
Name:
Relationship:
Contact Details:
REFERRAL INFORMATION
Current Medications:*
Antidepressants
Antipsychotics
Anxiolytics
Hypnotics and sedatives
Psychostimulants and nootropics
N/A
Current Services: (Please tick all that apply)
Adult Community Mental Health Team
CAMHS
Psychiatrist
Drug and alcohol service
Pain Mgmt. Services
Other
If other, please specify:
CONSENT – Patient or Parent/Guardian for a Child
Patient has been informed of the Mental Health services that ACT PHN provides. Patient understands the information provided in this referral is required to determine their eligibility for services. Patient consents to their de-identified information to be used for statistical purposes for ACT PHN and Department of Health.
Patient Consents:*
Yes
Under 12’s Parent/Carer willing to participate in sessions (group and/or individual) to support child towards best outcomes.
Parent/Carer agrees:
Yes
If your patient is linked in with ACT Community Mental Health Teams (Adult/CAMHS), do they consent to their information being shared for Triage purposes?:
Yes
No
Please ensure that both; the information provided is accurate and that the corresponding MHTP of the client is emailed through to Next Step intake, otherwise the referral cannot be processed (nextstepintake@mccg.org.au).
Please call (02) 6162 6111 or email nextstepintake@mccg.org.au if you require assistance or further information.
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