BHS MENTAL HEALTH REFERRAL
Referral date: <<Miscellaneous:Date (long)>>
Referral time: <<Miscellaneous:Time>> 	
Version 1
(2020-MD)	

REFERRED BY
Name: <<Doctor:Name>>
Practice: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Provider #: <<Doctor:Provider Number>>

	PATIENT DETAILS
Name: <<Patient Demographics:Full Name>>
Gender: <<Patient Demographics:Sex>> 
DOB: <<Patient Demographics:DOB (long)>>
Address: <<Patient Demographics:Full Address>>
Home ph: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Medicare #: <<Patient Demographics:Medicare Number>> <<Patient Demographics:Medicare Expiry Date>>
Pension: <<Patient Demographics:Pension Number>>
DVA #: <<Patient Demographics:DVA Number>>
ATSI: <<Aboriginal or Torres Strait Islander>>
<<Patient Demographics:Ethnicity>>
Interpreter required: <<Interpreter required?>>
Next of Kin: <<Patient Demographics:Next of Kin>>
<<Patient Demographics:Next of Kin Relationship>>
<<Patient Demographics:Next of Kin Phone>>	
PATIENT CONSENT

Patient consents to sharing medical information: <<Patient consents to sharing medical information>>
Is patient aware of referral:  <<Is patient aware of referral?>>	
SERVICE REQUIRED - fax referral to 5320 4028: <<Mental health service required>>
	
REFERRAL DETAILS

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

<<History of presenting complaint>> 	
SPECIAL ALERTS

Allergies:
<<Clinical Details:Allergies>>
Smoking status: <<Clinical Details:Allergies>>
Current pregnancy: <<Clinical Details:LNMP>> <<Clinical Details:EDC>>	
RISK ISSUES
Is the patient homeless?: <<Is the patient homeless?>>

Risk of suicide?: <<Any risk of suicide?>>
If yes, please provide details: <<Is suicidal, please provide details>>

Is the patient at risk of harm to themsleves or others?: <<Is patient at risk to themselves or others?>>
If yes, please explain in detail: <<If at risk of harm, please explain in detail>>

Any drug and alcohol issues?: <<Any drug and alcohol issues?>>
If yes, please provide details?: <<If drug and alcohol issues please explain in detail>>

Any history of violent or aggressive behaviour?: <<Any history of violent or aggressive behaviour?>>

Is the patient displaying psychotic symptoms?: <<Is patient displaying any psychotic symptoms?>>
If yes, please provide details: <<Describe psychotic symptoms>>

Any evidence of eating disorders?: <<Any evidence of eating disorders>>	
OTHER HEALTH PRORFESSIONAL/S SERVICES INVOLVED

Has the patient been admitted at any other hospital for a mental health condition?: <<Any previous admissions for mental health issues>>
If yes, where and what year (if known): <<If yes, where and what year>>

Is the patient under the care of any other health providers?: <<Is patient under care of any other providers>>
List names of any treating Psychiatrist or Psychologist: <<List names of any treating psychiatrist/ psychologist>>
	
PROGRESS NOTES

<<Summary:Progress Notes (Selected)>>	
PAST MEDICAL HISTORY (INCLUDING PSYCHIATRIC HISTORY)

<<Clinical Details:History List>>	
FAMILY & SOCIAL HISTORY

<<Clinical Details:Family History>> 
<<Clinical Details:Social History>>	
CURRENT MEDICATIONS

<<Clinical Details:Medication List>>	
LIVING ARRANGEMENTS

Does the patient live alone?: <<Does the patient live alone?>>
Does the patient have a carer?: <<Does the patient have a carer?>>	
INVESTIGATION RESULTS

<<Summary:Investigation Results (Selected)>>	

GP signature: ________________________________________________________________________

Patient Name:<<Patient Demographics:Surname>>, <<Patient Demographics:First Name>> DOB: <<Patient Demographics:DOB>>
Recipient: BHS Date of Report: <<Miscellaneous:Date>>