ATAPS
REFERRAL FORM
The Access to Allied Psychological Services (ATAPS) program aims to provide evidence-based short-term
psychological strategies to clients at risk of developing a mental disorder. ATAPS program includes the following
priority groups: Adults, Child Mental Health Services (CMHS), Aboriginal and Torres Strait Islander (ATSI) and
Suicide Prevention.
ATAPS referrals can be made by via the below professionals:
‘Referral’ – can be submitted via general practitioners, paediatricians and psychiatrists.
Referral Assessment
Please select one priority group that this referral is for and include date of referral
Date Click here to enter
text.
☐ Adults
☐ ATSI
☐ Suicide Prevention
☐ Children *
* Has the child’s legal guardian/ parent consented to this referral? ☐ Yes. If ‘No’ referral can’t be accepted.
Please select number of sessions required. Maximum of 6 sessions per referral, with re-referral from GP required
for each additional sessions.
☐ Initial 6 sessions
☐ Additional 6 sessions
☐ Further 6 sessions
Referral eligibility checklist. Please tick all that are applicable.
☐ Client resides in the Northern Territory
☐ Client requires short-term intervention
☐ Client on low income (GP to discuss with patient)
☐ Client unable to afford Psychological services under
Medicare
☐ Client is identified as being indigenous, or belonging
to a hard-to-reach group or from a multi-cultural
background
☐ Client has not used Better Access this calendar year
(at time of this document being completed)
☐ Client is currently not in mental health crisis care
☐ Client has a clinical diagnosis of an illness and is
assessed as being at risk of developing a mental disorder
☐ Client assessed as having low to moderate suicide risk (high risk clients are not eligible)
If high risk of suicide please refer immediately to Crisis Assessment Triage Team (CATT):
Health Network Northern Territory Ltd operating as Northern Territory PHN
We value: Relationships ● Equity ● Responsiveness ● Innovation ● Results
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1800 682 288 (1800 NTCATT) Free and confidential 24-hour hotline to qualified members of the Top End Mental
Health Service who can provide support and link callers with appropriate services in their area of the NT.
Client Details Confidential
Surname
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Telephone
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Given name
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Date of
birth
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Address
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Language(s)
Spoken at
home
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Is this client Aboriginal and/or Torres
Strait Islander
Postcode
How well does this
client speak English
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enter text.
Well ☐ Not well ☐
Require translator ☐
No ☐ Aboriginal ☐ Torres Strait Islander ☐ Both ☐ Unknown ☐
Next of kin/parent/legal guardian details
Surname
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Given name
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Date of
birth
Contact
details
t Click here to enter text.
e Click here to enter text.
Address
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Click here to enter text.
m Click here to enter text.
Postcode
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enter text.
Description of clients presenting concern(s)
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Client consents to GP liaising with ATAPS Triage service (client to sign and date below if they approve)
Signature:
Date: Click here to enter text.
Health Network Northern Territory Ltd operating as Northern Territory PHN
We value: Relationships ● Equity ● Responsiveness ● Innovation ● Results
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Referring source (must be completed if referral is sent by clinic/organisation/company)
Name
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Clinic/ Organisation
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Email
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t Click here to enter text.
☐ I have attached the clients Mental Health Treatments plan; or
☐ I will complete the clients Mental Health Treatment Plan and will fax it in the next two weeks (this is a mandatory
requirement for the clients to be triaged)
☐ I refer the client for individual therapy (up to 12 sessions per calendar year, with GP follow-up required after every
6 sessions and acknowledge that ATAPS Triage will assess this referral for client eligibility
☐ Client has requested specific psychologist: Click here to enter text.
Please send completed form to ATAPS.triage@catholiccarent.org.au or fax to (08) 8944 2099
For further information contact CatholicCare NT on t 1800 899 855
You may be contacted by ATAPS Triage to provide further clarification if required
Health Network Northern Territory Ltd operating as Northern Territory PHN
We value: Relationships ● Equity ● Responsiveness ● Innovation ● Results
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