Access to Allied Psychological Services (ATAPS) Project
Initial Minimum Data Set (MDS) - Tier 1 & Aboriginal, Homeless, Perinatal and Suicide/ Self-Harm
You must complete all fields and mail to IWSML with your invoice for the initial session
Your Name:
ATAPS Approval Number:
Date referred by GP:
Date you received referral:
Has this patient ever received ATAPS services in the past?
☐ Yes
Postcode of Patient:
Postcode of GP’s Practice:
☐ Yes
Diagnosis and Treatment
Patient Information
Have you received a copy of the GP Mental Health Care Plan?
Main language spoken at home
How well do they speak English?
☐ No
☐ English
☐ Other (Please specify):
☐ Very Well
☐ Well
☐ Not Well
Is the patient:
☐ Torres Strait Islander
Education Level
☐ Primary or below
Do they live alone:
☐Yes
☐ No
☐ Unknown
Low income earner?
☐ Yes
☐ No
☐ Unknown
Prior mental health care?
☐ Yes
☐ No
☐ Unknown
☐ Aboriginal
☐ Not At All
☐ Neither
☐ Year 7, 8, 9 or 10
☐ Child
☐ Year 11
☐ Risk of homelessness
☐ Year 12
☐ Tertiary
ICD – Diagnostic Categories
Referred for which Strategies
Receiving Psychotropic Medication
☐ Alcohol/Drug Use Disorder
☐ Psychotic Disorders
☐ Depression
☐ Anxiety Disorders
☐ Unexplained Somatic
☐ Unknown
☐ Other diagnosis:
☐ Diagnostic Assessment
☐ Psycho-education
☐ Interpersonal Therapy
☐ Narrative Therapy
☐ Other Strategies:
☐ None
☐ Benzodiazepines & Anxiolotics
☐ Antidepressants
☐ Phenothiazines &Tranquilisers
☐ Mood Stabilisers
Date of session:
First Session Details
☐ No
Cognitive-Behavioural Therapy (CBT)
☐ Behavioural Intervention
☐Cognitive Intervention
☐ Relaxation Strategies
☐ Skills Training
☐ Other CBT Interventions:
Duration of Session:
Strategies Provided
☐ Diagnostic Assessment
☐ Psycho-education
☐ Interpersonal Therapy
☐ Narrative Therapy
☐ Other: _______________________
ATAPS Stream
☐ Dep Anx St (use DASS 21)
DASS 21 Pre Scores
Stress:
Attended: ☐ Yes
☐No
Client Signature:
Cognitive-Behavioural Therapy (CBT)
☐ Behavioural Interventions
☐ Cognitive Interventions
☐ Skills Training
☐ Other CBT Interventions:
_______________________
☐ Self Harm (use MSSI)
☐ Perinatal (use EPDS)
Depression:
Anxiety:
Modified Scale for Suicidal Ideation Pre Score (MSSI):
Edinburgh Pre Scores (EPDS):
Is this patient continuing with you for sessions 2-6 (session 2-12 for Self Harm)?
☐ Yes
☐ No
The information I have provided on this form is a true and accurate record of services provided by me
Signed: ________________________________________ Date:
IWSML March 2014
This document is no longer controlled once printed