Secure General Referral Form

Attention AttentionJames PaisleyJamie StantonHelen Shield

From:

Phone Number

Office Location

Referring Doctor's Details

Doctor Name

Provider Number

Practice Name

Practice Address

Phone Number

Email

Preferred Contact Method Preferred Contact MethodPhone NumberEmail

Patient Details

Patient Name

Date of Birth

Gender Gender Male Female Patient Defined

Please Specify

Address

Home Number

Mobile Number

Email Address

GP Mental Health Care Plan

Presenting Problem/Diagnosis:

Relevant Medical History: Has the person ever received specialist mental healthcare? Relevant Medical History: Has the person ever received specialist mental healthcare? Yes No

Other Mental Health Professionals involved in Patient Care:

Other relevant information/medical history/medication:

Family History

Personal History

Mini Mental Status Examination

Appearance and General Behaviour Appearance and General Behaviour Normal Other

Mood Mood Normal Depressed

Thinking (content, rate, disturbances) Thinking (content, rate, disturbances) Normal Other

Delusions (grandeur, paranoia) Delusions (grandeur, paranoia) Present Absent

Perception (hallucinations) Perception (hallucinations) Normal Other

Sleep (insomnia, early wakening) Sleep (insomnia, early wakening) Normal Other

Cognition Cognition Normal Other

Appetite Appetite Normal Increased Decreased

Attention/Concentration Attention/Concentration Normal Other

Motivation/Energy Motivation/Energy Normal Other

Memory (short term) Memory (short term) Normal Other

Memory (long term) Memory (long term) Normal Other

Ability to make rational decisions Ability to make rational decisions Normal Other

Insight Insight Normal Other

Anxiety Anxiety Normal Other

Orientation (time/place/person) Orientation (time/place/person) Normal Other

Speech (volume/rate/content) Speech (volume/rate/content) Normal Other

Mini Mental Status Examination - Suicidality

Suicide Ideation Suicide Ideation Yes No

Suicidal Intent Suicidal Intent Yes No

Risk to Others Risk to Others Yes No

Current Plan in Place Current Plan in Place Yes No

Additional Information