ATAPS Referral Form
Referral date:
/
/
Client Details (Information required for FMPML and AHP purposes)
Title:
Last Name:
Date of Birth:
/
First name:
/
Gender:
Phone:
Mobile:
Aboriginal or Torres Strait Islander?
Education:
Male
Tertiary
_
_______
Female
Does the client live alone
Yes
Year 12
Does the client have a Healthcare card?
No
Yes
No
Unknown
Year 11
Year 10
Yes
No
Healthcare card number
_
Year 7-9
Primary
Expiry Date
Is the child’s family financially disadvantaged? Please specify;
Is an interpreter required?
Yes
Are other services involved?
DHS
Yes
No
Public Mental Health
D&A services
Other specify
Referring Medical Practitioner
Allied Health Provider
Practice Name :
FMPML to allocate
Name:
GP to allocate from ATAPS Approved Providers
(give
details below)
Phone:
Name:
Fax:
Email:
Phone:
_________________________________
ATAPS Service Requested (Information required for FMPML purposes)
Standard ATAPS (Better Outcome in
Mental Health Care)
Must attach MHTP & K10
Has the person been referred to ATAPS in the past?
Yes
No
Unknown
Is this a request for further sessions?
Perinatal – must have PND diagnosis
Must attach MHTP, K10 & EPNDS
Suicide Prevention Service (SPS)
Must attach SPP Risk Assessment
Tool for GP’s no MHTP required
Aboriginal & Torres Strait Islander
Must attach MHTP
& K10
Child Mental Health Service (CMHS)
Must attach Child Treatment Plan & SDQ
ATAPS Provider at headspace
Yes
No
If yes has Mental Health Care plan been reviewed?
Has the client been referred for Better Access since
Yes
Yes
1st
No
January 2014
No
If yes, number of sessions received under Better Access:
SPP – Referrals will be processed by FMPML between 9 – 3pm Mon–Thur
and between 9-2pm Friday.
Client provided with ATAPS Suicide Support Line No.: 1800 859 585
GP must book a call back on 1800 859 585, outside of referral processing
hours,weekends and public holidays.
SPP risk level:
Low without mean, intent or plan
Moderate
High
Low with mean, intent or plan
www.fmpml.org.au
Level 1, 311 Main Street Mornington Victoria 3931
PO Box 107 Mornington Victoria 3931
t 03 5973 5655 f 03 9708 8157
ABN: 80 156 428 572
Frankston-Mornington Peninsula Medicare Local acknowledges the financial support of the Australian Government Department of Health.
General practice referral
If yes, please specify:
No Please provide details of what is required
Diagnostic Information- ATAPS Standard,
Perinatal, Suicide, ATSI
Diagnostic information- Child
ICD 10 Diagnostic Categories/Codes
ICD 10 Diagnostic Categories/Codes
F1 Alcohol and Drug Use Disorders
F2 Psychotic Disorder
F3 Depression
F4 Anxiety Disorder (mild to moderate only
No formal diagnosis (SPP only)
Other specify
F3 Depression
F4 Anxiety Disorder (mild to moderate only)
F50 Eating disorder
F94.1 Attachment disorders
F51 Sleep disorders
F43.2 Adjustment disorder
F90 Behavioural disorders
Includes, Conduct, ADHD, ADD,
ODD & Disruptive
Other specify
At risk of developing a disorder Specify disorder
Behavioural issues
Please specify
Mental Health Symptoms
Overview of Mental Health Symptoms:
Severity of Mental Health Symptoms:
Mild
Moderate
High
Psychological Measure
K10 Score:
DASS 21 or 41 (circle):
SPS Sheehan Suicide Tracking Scale (SSTS):
Edinburgh Post Natal Depression Scale (EPNDS):
Strengths and Difficulties Questionnaire:
Other (please specify measure & score):
Current Psychotropic Medication (Please tick all that applies)
None
Benzodiazepines & Anxiolytics
Phenothiazines & Tranquilisers
Antidepressants
Mood Stabilisers
Other specify
Additional Supporting Information
Strategies Referred for (select all that apply)
Psychoeducation
Interpersonal Therapy
Cognitive Behavioural Therapy (CBT)
Skills Training
Behavioural Intervention
Relaxation Strategies
Narrative Therapy
Other specify
Children Interventions
Behavioural Intervention
Parenting/Family based Interventions
Cognitive Behavioural Therapy (CBT)
www.fmpml.org.au
Level 1, 311 Main Street Mornington Victoria 3931
PO Box 107 Mornington Victoria 3931
t 03 5973 5655 f 03 9708 8157
ABN: 80 156 428 572
Frankston-Mornington Peninsula Medicare Local acknowledges the financial support of the Australian Government Department of Health.
Alternative Mental Health Programs
If the client is not eligible for ATAPS is consent provided for FMPML Mental Health Team to discuss the referral with the
Mental Health Nurse Incentive Program (MHNIP) or Partners in Recovery (PIR).
Client/Parent/Guardian Consent______________________________
GP Consent _______________________________
CLIENT / PARENT / GUARDIAN CONSENT: (Client
/ Parent or Guardian to complete)
Signature:_________________________________
I have read the Client Information Sheet and I give consent for
my health information to be shared between my GP, FrankstonMornington Peninsula Medicare Local and an ATAPS Provider.
I also consent for my de-identified data to be forwarded to the
Department of Health for evaluation purposes
Name:____________________________________
GP CONSENT:
Signature:_________________________________
I have discussed the proposed referral to an AHP with the
patient and / or parent / guardian and am satisfied that the
patient and / or parent / guardian understands the proposed
collection, use and disclosures of health information as detailed
above, and has provided consent to these.
Date: ____________________________________
Date: ____________________________________
Please fax completed form and a copy of the Mental Health Treatment Plan to the FMPML Assessment & Referral Officer (03) 9708
8157
www.fmpml.org.au
Level 1, 311 Main Street Mornington Victoria 3931
PO Box 107 Mornington Victoria 3931
t 03 5973 5655 f 03 9708 8157
ABN: 80 156 428 572
Frankston-Mornington Peninsula Medicare Local acknowledges the financial support of the Australian Government Department of Health.