BHS SMART GP MENTAL HEALTH REFFERAL
Referral date: <FormattedDate> 
Referral time: <CurrentTime>	Version 1
(BP 2020)	

REFERRED BY
Name:<DrDetails>
Practice:<Practice>
Address:<UsrAddress>
Phone: <UsrPhone>
Fax:<UsrFax>
Provider #: <DrProviderNo>	PATIENT DETAILS
Name:<PtFullName>
Gender:<PtSex>
DOB:<PtDoB>
Address:<PtAddress>
Home Ph:<PtPhoneH>
Mobile:<PtPhoneMob>
Medicare #:: <PtMCNo><PtMCLine><PtMCExpiry>
Pension:<PtPensionNo>
DVA:<PtDVANo><PtDVACard>
ATSI:<PtEthnicity>
Interpreter required:<Interpreter required?>
Next of Kin: <NOKName><NOKRelation> <NOKContact><NOKContact2>	
PATIENT CONSENT

Patient consents to sharing medical information: <Patient consents to sharing of medical information>
Is the patient aware of the referral: <Is the patient aware of the referral?> 	
MENTAL HEALTH SERVICE REQUIRED- Fax referral to 5320 4028: <Mental Health Service requested>
	
REFERRAL DETAILS

Are you the patient's usual GP:  <Are you the patient's usual GP?>
If not, name of usual GP: <If not, provide name of Usual GP & Practice>
How long have you known this patient?: <How long have you known this patient>	
REASON FOR REFERRAL & PRESENTING PROBLEM

<Reason for referral- presenting problem> 	
SPECIAL ALERTS:

Allergies: <Reactions>
Smoking status: <SmkStatus>
Alcohol history: <AlcHx> 
Current Pregnancy: LMP: <LMP> EDC: <EDC><Gestation> 	
RISK ISSUES

Is the patient homeless?: <Is the patient homeless>
Risk of suicide?: <Any risk of suicide>
If yes, please provide details: <If yes, please provide details>
Is the patient at risk of harm to themselves or others?: <Is the patient at risk of harm to themselves or others> 
If yes, please explain in detail: <If at risk of harm please explain> 
Any drug and alcohol issues?: <Any drug and alcohol issues>
If yes, please explain: <If any drug and alcohol issues please explain>
Any history of violent or aggessive behaviours?: <Any violent or aggressive behaviours>
Is the patient displaying psychotic symptoms?: <Is patient displaying psychotic symptoms>
If yes, describe psychotic symptoms: <If yes, describe psychotic symptoms>
Any evidence of eating disorders?: <Any evidence of eating disorders>	
OTHER HEALTH PROFESSIONALS/SERVICES INVOLVED

Has the patient been admitted at any other hospital for a mental health condition?: <Has patient been admitted for a mental health condition at any other hospital?>
If yes, where and what year (if known): <If treated at another hospital please state, include year if known>
Is the patient under the care of any other health providers?: <Is patient under care of other providers?>
List names of any treating Psychiatrist or Psychologist: <Please list names of treating psychiatrist or psychologist>
	
PROGRESS NOTES: 

<Visits>	
PAST MEDICAL HISTORY (INCLUDING PSYCHIATRIC HISTORY): 

<PMHAll>  	
FAMILY & SOCIAL HISTORY: 

<FamilyHx> <SocialHx>	
CURRENT MEDICATIONS: 

<CurrentRx>	
LIVING ARRANGEMENTS:

<Lives alone> 
<Has carer?>	
INVESTIGATION RESULTS: 

<Ix>	

GP SIGNATURE: