ATAPS REFERRAL FORM
Telephone ATAPS HOTLINE on
9998 0931
to receive patient unique identification number
GP to complete ALL SECTIONS of the Referral then FAX directly to ALLIED HEALTH PROFESSIONAL
AHP must be an SNSBMLapproved ATAPS provider
GP Mental Health Treatment Plan Completed
AHP Initial Consultation Date :
Patient Unique Identification Number:
Referring GP
Expiry Date :
GP Provider Number
Patient Profile
Primary Language
Postcode of Practice
Date of Referral
English Level
Education
Patient Initials :
English
Very well
Primary or lower
Date of Birth :
Italian
Well
Secondary (Yr10)
Greek
Not well
Secondary (Yr11)
Cantonese
Not at all
Secondary (Yr12)
Mandarin
Unknown
Tertiary
Male
Female
POSTCODE :
ATSI Status :
Aboriginal
Torres Strait Islander
Unknown
Neither
Lives alone? Y
N
Arabic
Vietnamese
Other
Low income
Tier 1
History & Eligibility
Tier 2
Unemployed / Under-employed
Perinatal Depression
Pension/Concession card
Perinatal Anxiety
Has the patient ever received specialist mental health
care before?
Single Parent
Risk of suicide
Y
Youth or full time student
Risk of homelessness
Youth 12-18
Aboriginal
Please indicate type of Re-referral:
Culturally & Linguistically
Diverse Backgrounds
Torres Strait Islander
Initial referral
Children 6-12
Exceptional Circumstances
Primary Diagnosis
Referred for
Antenatal depression
Postnatal Depression
Child’s DOB
Benzodiazephines
Phenothiazines & Tranquilisers
Antidepressants
Mood stabilisers
No Medication
OR
Emergency Dept
Psychiatrist
Behavioural Interventions
Cognitive Interventions
Relaxation Strategies
Skills Training
Other
Medications
Re-referral
GP
CBT
Alcohol & Drug Use
Psychotic Disorders
Depression
Anxiety Disorders
Unexplained somatic disorders
Other
Unknown
Unknown
Referral Type
Diagnostic assessment
Psycho-education
Interpersonal Therapy
Narrative Therapy
Other
State weeks gestation
N
Maternal Health Nurse
Provisional referral eg Paediatrician
Other
GP Assessment
AHP Referred to
Outcome measurement tool used:
Eg K10, DAS21, EPDS
Name:
Score:
Phone:
Group Therapy Sessions
Patient referred to group therapy
Provider:
Fax:
Mental Health Professional to fax the above de-identified information (cut off below section) to
9998 0926
----------------------------------------------------------------------------------------------------------------------
Name:
(Given)
(Surname)
Address:
Phone:
(Home)
(Mob)
I have read the Patient Information leaflet and I give consent for my clinical
information to be shared with the ATAPS Mental Health Professional. I
agree to de-identified information (consisting of the information above the
dotted line) to be transferred to SNSBML to be used for evaluation purposes
only.
Signature:
________________________________