ATAPS Mental Health Referral Form
Access to Allied Psychological Services
Forward completed referral form together with the Mental Health Treatment Plan/Child Treatment Plan to Gold Coast Primary Health Network
via Medical Objects (GCML Referrals) or Fax: 07 5612 5499
Referring GP:
Phone:
Practice Address: (practice stamp if available)
Practice Post Code:
Name of preferred ATAPS Mental Health Professional: *If MHP is not nominated GCPHN will allocate to most appropriate provider
Preferred Gender of MHP:
 Either
 Male
 Female
Referring GP Signature:
Please note one referral = 6 sessions. A Patient must be reviewed by the GP before a further 6 sessions can be provided.
The subsequent allocation of 6 sessions requires an ATAPS Mental Health Review form to be completed.
Referral Date:
Patient Name:
DOB:
 M  F
Gender:
Address:
Postcode:
Home Ph:
Mobile Ph:
Next of Kin/Guardian:
Relationship to Patient:
Patient/Parent or Guardian provides consent for this referral:
Medicare No:
 Y
 N
Health Care/ Pension Card No:
Expiry Date:
(*Must hold one of these to be eligible for ATAPS)
Is the Patient a low income earner?
 Y  N
Does the Patient have Private Health Insurance?  Y
Date Mental Health Treatment Plan (MHTP) or Child Treatment Plan (CTP) Completed
(*Must have one of these to be eligible for ATAPS)
__________ /__________/___________
Does the Patient speak a language other than English?  Y
Does the Patient identify as Aboriginal or Torres Strait Islander?
Does the Patient live on their own?  Y
 N
(* MHTP or CTP is required to accompany this referral)
If yes, what language?
 N
 Very Well
If yes, how well does the Patient speak English:
MHTP or CTP Attached :  Y
 N
 Well  Not Well  Not at all
 No  Aboriginal  Torres Strait Islander  Both
 N
Does the Patient have access to transport?  Y
 N
What is the highest level of education the Patient has completed?
 Primary  Year 10  Year 11  Year 12  Tertiary
Has the Patient received Better Access services this calendar year?
Has the Patient received Specialist Mental Health Care before?
 Y  N
 Y  N
OUTCOME TOOL SCORE:
ATAPS Program Referred to: (select one)




Aboriginal & Torres Strait Islander Mental Health Service
Child ATAPS (12 years and under)
General ATAPS (Anxiety/Depression)
Perinatal Depression If Postnatal - Infant DOB:
K5 Score:
SDQ Score:
K10 Score:
EPDS Score:
(up to 1 year of age to be eligible for ATAPS Perinatal Program)
 Suicide Prevention (non acute/non crisis)
MSSI Score:
Suicide Prevention Referrals ONLY Please select rating category for each issue or attach Mental Health Service Acute Care Team, discharge summary.
Issue
Suicide / Self Harm History
Intent / Plan / Thoughts
Longstanding Problems
Psychological Factors
Lack of strengths / Support
Overall Assessment of Risk
High
High
High
High
High
High
/
/
/
/
/
/
Risk Categories
Moderate / Low
Moderate / Low
Moderate / Low
Moderate / Low
Moderate / Low
Moderate / Low
Please note:
If majority of Risk Categories are rated High
Acute Care Team referral may be more appropriate.
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Diagnosis/Presenting Complaint (please specify below)
Adjustment Disorder
Depression
Eating Disorder
Neurasthenia
Sexual Disorders
No formal diagnosis
Anxiety Disorders
Dissociative Disorder
Enuresis
Psychotic Disorders
Unexplained Somatic Disorder
Other:
Conduct Disorder
Drug & Alcohol / Substance Abuse
Hyperkinetic Disorder
Sleep Problems
Unknown
If a child is ‘at risk of’ developing any of the above, please explain under the ‘Presenting Issues’ below.
Referred for which Focused Psychological Strategies: (please specify below)
Diagnostic Assessment
Cognitive Intervention (CBT)
Skills Training (CBT)
Narrative Therapy
Psycho-Education
Interpersonal Therapy
Behavioural Intervention (CBT)
Relaxation Strategies (CBT)
Other CBT Intervention
Parent Training in Behaviour Management (Child ATAPS Referral Only)
Is the Patient receiving Psychotropic Medication?
If yes, please indicate below:
 Benzodiazepines and Anxiolytics
 Phenothiazines and Major Tranquillisers
 Y  N
 Antidepressants
 Mood Stabilisers
Presenting issues are mild to moderate in severity?
 Y  N
Patient requires short-term psychological intervention?
 Y  N
Presenting Issues:
Patient History: (Medical, Surgical, Social & Family)
Treatment Goals:
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Suicide Prevention Program Risk Assessment (Circle Issue or Example of Issue):
Issue
Examples of High Rating
Examples of Medium Rating
Suicide/Self-Harm History;
Family History of suicide;
Multiple attempts of low
lethality;
 Previous attempts or exposure to
Previous attempt of high
attempts
lethality;
Repeated threats;
 Lethality
Repeated self-harm.
Infrequent self-harm;
Examples of Low Rating
Nil or vague thoughts;
No recent attempt of low
lethality and low intentionality
Recent attempt of moderate
lethality.
Long standing problems;
 History of mental illness
 History of sexual/physical
abuse/neglect/domestic violence
 Family breakdown, child custody issues
 Financial difficulties, unemployment,
homeless
 Serious physical illness/ disability
 Chronic pain or illness
Intent/Plan/Thoughts;
 Access to means
 Clear plan
 Evidence of clear intention
 Suicidal Thoughts
Psychological factors;
 Depression/hopelessness/
isolation/anger;
 Psychotic symptoms;
 Stressors in last 6 months (eg. Recent
crisis, major loss or trauma, or
anniversary)
Several factors in this list are
involved
Some factors in this list are
involved
Nil or one factor in this list are
involved
Continual/specific thoughts;
Frequent thoughts;
Nil or vague thoughts;
Evidence of clear intention;
A plan that is not fully
developed;
No real plan;
Access to means;
A well-developed plan
Moderate depression;
Nil or mild depression;
Command hallucinations or
delusions about dying;
Some sadness;
Nil or mild sadness;
Some symptoms of
psychosis;
No psychotic symptoms;
Preoccupied with
hopelessness, despair, feelings
of worthlessness;
High level of stressors in last 6
months.
Unemployed;
Lack of supportive and stable
relationships / hostile
relationships;
Others not available or unwilling
/ unable to help.
Overall Assessment of Risk;
Clinical judgement based on the ratings
for the Issues listed above.
Ambivalent desire to end their
life
Severe depression;
Severe anger, hostility;
Lack of Strength & Supports;
 Availability of supports
 Stability of employment and
 Relationships
No intention to end their life
Potential access to means;
Most of the Issues above rate in
the High Category
Some feelings of
hopelessness;
Moderate anger, hostility;
Moderate level of stressors in
last 6 months
Employment either unstable
or unsatisfying;
Few relationships lacking
stability;
Feels hopeful about the
future;
Nil/mild anger, hostility;
Nil or mild stressors in the last
6 months.
Stable satisfying
employment/study;
Stable relationship/s;
Others available but unwilling
/ unable to help consistently.
Support from others that are
willing and able to help
consistently.
Most of the Issues above rate
in the Moderate category.
Most of the Issues above rate
in the Low category.
Acute Care Team referral may
be more appropriate
V1.0 09/07/2015