ATAPS REFERRAL
INNER EAST AND NORTHEAST
Fax this completed template and any other relevant information to 8822
8560
LOW INCOME CLIENT/FAMILY:  Yes  No
If you ticked “no”, STOP here. This program is only available to low income clients or families.
CLIENT IS HIGH RISK OR NEEDING CRISIS INTERVENTION:  Yes  No
If you ticked “yes”, STOP here. This program is not and acute mental health service .
REFERRAL TYPE:
PREFERRED PROVIDER
 Adult (>25yrs)
 Perinatal depression
(GP referrers only)
(GP and provisional referrers)
 Adolescent/Youth (12-25yrs)  Child (<12yrs)
(GP referrers only)
(GP and provisional referrers)
Or
 EMPHN to select provider
REFERRER NAME: ______________________________________________________________________________
POSITION/TITLE: ______________________________________________________________________________
(For provisional referrers)
NAME AND ADDRESS OF REFERRER’S ORGANISATION/PRACTICE: ______________________________________
PHONE: ___________________ FAX: ___________________ EMAIL: ____________________________________
CLIENT’S NAME: ______________________________________ DOB: ______________  MALE
 FEMALE
CLIENT’S ADDRESS: ____________________________________________________________________________
PHONE: ___________________ PARENT/GUARDIAN’S NAME: _________________________________________
(If applicable)
USE OF MEDICARE BETTER ACCESS FOR THIS CLIENT IN THIS CALENDAR YEAR:  Yes  No
If yes, number of sessions: ______________________________________________________________________
USE OF ATAPS FOR THIS CLIENT IN THIS CALENDAR YEAR:  Yes  No
If yes, number of sessions: ______________________________________________________________________
INTERPRETER REQUIRED:  Yes  No
If yes, in which language: ______________________________
IS THE CLIENT OF ABORIGINAL OR TORRES STRAIT ISLANDER DESCENT?
 Aboriginal  Torres Strait Islander (Please tick all that are appropriate or leave blank if not applicable.)
FOR NON-GP REFERRALS (provisional referrals)
CLIENT’S GP AND NAME OF GP CLINIC: ____________________________________________________
PHONE: ____________________________________ FAX: ____________________________________
CLIENT INFORMATION
DIAGNOSIS AND CURRENT PRESENTING ISSUES:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
CURRENT AND PREVIOUS MENTAL HEALTH TREATMENT(S)/INTERVENTIONS:
Please outline history of previous counselling, interventions and assessments including name(s) of agencies.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
OTHER RELEVANT INFORMATION/CONTEXTUAL HISTORY:
Please include current medications.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
REFERRER SIGNATURE: __________________DATE __________________
CLIENT CONSENT – Written consent is mandatory for all ATAPs referrals
I give consent for my /my child’s information to be shared with the ATAPS provider, and to non-clinical
information being provided to Eastern Melbourne PHN for administration and service evaluation
purposes.
CLIENT OR PARENT/GUARDIAN’S NAME: _________________________________________________
CLIENT OR PARENT/GUARDIAN’S SIGNATURE: ___________________________ DATE: ____________
For Child Mental Health/PS4 Kids and PND Referrals
please proceed to the next page.
COMPLETE THIS SECTION FOR CHILD MENTAL HEALTH/PS 4 KIDS
1.







CURRENT EMOTIONAL HEALTH ISSUES/CONCERNS
Mood (irritability, crying, feeling sad)
Sleep (routine, hygiene, disrupted)
Energy (decrease, hyperactivity)
Recent stressful/traumatic event
Attention/concentration
Social difficulties
Behavioural issues
2.




Anxiety (avoidance, phobias, separation)
Appetite (increased, decreased)
Toileting (encopresis, enuresis, bed wetting)
Somatic complaints (no physical cause)
Academic performance
Obsessive behaviours
CONTEXTUAL HISTORY-biological, physiological, social history , family history of mental health disorders
Exposure to/ past experience of trauma/violence
Disrupted attachment history
Developmental delay/ issues
Physical illness
3.
















Parent with mental health issues
Parent with substance misuse issues
Parent with significant physical illness
Previous counselling/treatment





Current self-harm behaviour
History of suicidal behaviour
Current substance misuse
History of aggression (physical, verbal, harm)
History of running away behaviour
RISK FACTORS
Exposure to self-harm/suicidal behaviours
History of self-harm behaviour
Exposure to substance misuse
Current aggression (physical, verbal, harm)
Current running away behaviour
Recent/current school suspensions
4.
COURT ORDERS (current)
 IVO  Family Court  Child Protection Order
Expiry date of order: ________________
COMPLETE THIS SECTION FOR PERINATAL DEPRESSION REFERRALS
EDINBURGH POSTNATAL DEPRESSION SCREENING SCORE: __________INFANT’S DOB: ___________
1.
RISK TO SELF AND/OR INFANT
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2.
MOTHER/INFANT RELATIONSHIP ISSUES
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
3.
FAMILY CONCERNS eg sibling relationships/development, D/A, violence, financial difficulties, physical illness
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
4.
 IVO
COURT ORDERS (current)
 Family Court
 Child Protection Order
Expiry date of order: __________________