GP MENTAL HEALTH TREATMENT PLAN (GP MHTP)
PATIENT ASSESSMENT SUMMARY (2700/2701 OR 2715/2717)
Patient’s Full Name
Date of Birth
Address
Phone
Carer/emergency name
& contact details
Other care plan
Eg GPMP / TCA / CDM
YES 
NO 
GP Name / Practice /
Provider Number
AHP or nurse currently
involved in patient care
Medical
Records No.
PRESENTING ISSUE(S)
- mental health issues &
bio-psycho-social
symptoms; onset/events
PATIENT HISTORY
- biological (substance
use, surgery, injury, dx,
vascular, metabolism,
arousal/sleep, illness)
- psychological (fam MH
hx, prev dx/tx/response)
- social (work, ed, r’ship)
MEDICATIONS
(attach more if required)
ALLERGIES
ANY OTHER
RELEVANT
INFORMATION
RESULTS OF MENTAL
STATE EXAMINATION
Record summary &
attach evidence of patient
full examination
SUICIDE / RISKS AND
CO-MORBIDITIES
self &/or harm to others
see attached guidelines
OUTCOME TOOL USED
K10/ DASS / SDQ / PND
SF12 / HoNOS / GDS /
HEADSS/ DSC /other
DIAGNOSIS /
comorbidity
(attach formulation)
Indicate if provisional
formulation warranting
further assessment
Suicide: [ ] ideation; [ ] plan; [ ] intent; [ ] means; [ ] past attempt; [ ] fam hx of suicide
N.B. If risk noted, close monitoring & early review is indicated.
RESULTS & IMPLICATIONS (i.e. level of psychological distress indicated;
attached copy of assessment to enable tx monitoring)
GP MENTAL HEALTH TREATMENT PLAN
PATIENT PLAN
REFERRALS
PATIENT NEEDS
GOALS
TREATMENTS
What are the key issues/concerns
central to the patients’ problems?
Record mental health goals
agreed to by patient and GP
What treatments, actions and support services will address patient goals?
(Clarify role of patient, GP, allied health & others)
Attach copies of referrals by GP as needed
for further assessment & initial six sessions
of treatment. 4 additional subject to review.
To whom & for what service…..
CRISIS / RELAPSE
(Plan for crisis intervention or
relapse prevention & strategies or
resources to support and maintain
treatment compliance)
COMPLETING THE PLAN
On completion of the plan, the GP is to record that s/he has discussed with the patient (and/or carer/guardian if required) and the patient has accepted the assessment findings & treatment strategy:
[ ] the assessment.
[ [ the treatment strategies and role of GP, patient and other service providers
[ ] the agreed date for review; and
[ ] GP offered a patient copy of the plan and to carer (if agreed by patient).
APPROPRIATE PSYCHO-EDUCATION PROVIDED
YES 
NO 
DATE PLAN COMPLETED:
PLAN ADDED TO THE
PATIENT’S RECORDS
PATIENT SIGNATURE: I accept this MHT Plan &
consent to share it with providers named in the plan.
YES 
NO 
COPY (OR PARTS) OF THE PLAN
OFFERED TO OTHER PROVIDERS
YES

NO

NOT REQ’D 
REVIEW DATE:
(initially 4 weeks to 6 months after completion of plan
unless mod-high risk indicates early review)
REVIEW COMMENTS (Progress on actions and tasks) N.B. If symptoms have not resolved, a new assessment form may be used for the Review.
OUTCOME TOOL REVIEW RESULTS
COMPREHENSIVE SUMMARY OF MENTAL STATE EXAMINATION
Patient Name:
Date of MSE:
Appearance
Indicators: Overall gestalt,
appearance, hygiene, dress,
posture (including incongruities)
Behaviour
Indicators: activity level
(mannerisms, gestures, alert,
lethargic, limp, rigid, relaxed,
combative, hyperactive, bored,
vigilant. Preoccupied, distracted),
posture, balance, gait, coordination,
abnormal movements, startle
response, habits, rituals,
stereotyped movements.
In-session Rapport:
Indicators: eye contact,
cooperativeness, attentive, frank,
distracted, defiant ,guarded,
humorous ,defensive, dependency,
friendliness, withdrawal,
evasiveness, fear, anxiety, hostility,
suspiciousness, indifference,
suggestibility, historian +/-..
Note level of rapport.
Affect & Mood
Indicators: elevated, euphoric,
euthymic, dysphoric, empty, labile,
anxious. Stable vs labile.
Appropriateness to situation. Affect:
range (normal, expansive, blunted,
restricted, flat), appropriateness,
control, congruity, suspicion,
anxiety, fear, anger, issues related
to particular affects.
Thought Processes
Indicators: tempo, fluency, goaldirection, coherence, interruptions,
formal thought disorder, derailment,
vague, disorganised, blocked, flight
of ideas, tangential, incoherent,
punning, neologism, evasive,
circumstantiality, perseveration,
poverty of speech, intensity.
Thought Content
Indicators: obsession, delusions,
compulsion, ideas of reference
(controlled, broadcasting, bizarre)
illusion, depersonalisation, de ĵa vu,
phobia, flashback, abnormality of
body image, distortion of time,
confabulation, fabrication;
preoccupied (identity, self-efficacy,
physical/mental health, past, future).
Perceptual Disturbances
Indicators :sensory distortions,
hallucinations (voices, visions
content, setting, sensory systems),
delusion (persecutory, somatic,
grandeur), depersonalisation, de ĵa
vu, phobia, flashback, abnormality
of general or special sensation,
abnormality of body image,
distortion of time,
Insight and Judgement
awareness of having a problem,
awareness of nature of problem,
desire for help.
/
/
FORMULATION of Diagnosis/ Provisional Diagnosis
Patient Name:
Date of Assessment:
/
/
Presentation:
________________________________________________________________
Describe repetitive themes,
issues or patterns,
behaviours/symptoms of
concern, onset, impact on
functioning)
________________________________________________________________
Precipitation:
________________________________________________________________
________________________________________________________________
recent triggering events
associated with the
presentation or exacerbation
of an existing condition
________________________________________________________________
Pattern:
________________________________________________________________
historical account of current
presentation and prior
episodes of difficulties
________________________________________________________________
________________________________________________________________
________________________________________________________________
Predisposition:
social, emotional and
psychological factors that
have led to the development
of the problem
Perpetuating Risk:
factors that are maintaining
the problematic behaviours
or symptoms
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Protective Factors:
that may assist the
individual to resolve or
manage the identified
problems
________________________________________________________________
________________________________________________________________
ASSESSMENT – Diagnostic Profile of Mental Disorder
DSM5 clusters these three dimensions of well-being (former Axes I,II & II of the DMS-IV)
Clinical Disorders/
Syndromes
Developmental /
Personality Factors
Medical Conditions/
Physical Syndromes
Psychosocial &
Environmental
Stressors
Assessment of
Disability Level
Symptom impact on social, occupational and other important aspects of daily functioning
e.g. superior functioning, minimal impact, transient, mild, moderate, severe, incapacitation…