Marathon Health ATAPS/MHSRRA Mental Health Programs
Referral Form and Child Treatment Plan
Submit via secure fax: 02 6882 7224 or to
mentalhealthargus@marathonhealth.com.au
Please complete all details – incomplete referrals will be returned to the GP
REFERRAL DATE
REFERRING GP DETAILS
GP Name
Address
Town
Phone
Fax
Postcode
REFERRAL TYPE (not all programs available in all locations – please contact Marathon Health for program availability)
General ATAPS / MHSRRA
Aboriginal and Torres Strait Islander
Child under 12 years Parent/carer name:
Perinatal Depression Due date: ______ or
Please tick:
Initial Referral
Preferred mental health provider
ELIGIBILITY
Financial Status:
Review
has baby <12mths
Re-Referral - approx. date patient last access ATAPS:
Next Available OR
Name:
Health Care Card holder
Low income earner
Completed, signed and attached
Genuine financial hardship
N/A – not eligible for ATAPS
N/A – not eligible for ATAPS
Mental Health Treatment Plan:
No
Unknown
Is patient currently accessing other
Yes (describe):
mental health services?
No
Has patient received mental health services with a private provider under
Yes – not eligible for ATAPS
the Better Access initiative (Medicare) within this calendar year?
CLINICAL ELIGIBILITY
Anxiety
Depression
Alcohol/Drug Use Disorder
Provisional
Perinatal Depression
Childhood Behavioral Disorders (Children under 12 only)
Diagnosis:
Unknown
Referred
for:
No Formal Diagnosis
Other: _____________________________
Diagnostic Assessment
Cognitive Behavioural Therapy
Psycho-Education
Narrative Therapy
Interpersonal Therapy
Family Therapy (for PND/Children only)
Parent Training in Behaviour Management (Child referrals only)
Other: _____________________________
Mild
Moderate
Severe /persistent
presentation
Severity of
Risk assessment
ATAPS is not an urgent service – wait times may apply
Would patient benefit from short term intervention
(6-12 sessions)
Low – not urgent
Moderate – not urgent
High Risk / acute / urgent – not eligible for ATAPS
Yes
No, patient requires long-term support - not eligible for ATAPS
If patient at high risk or severely unwell they may not be suitable for ATAPS – please contact 1800 011 511 (24 hrs) for appropriate services
PATIENT INFORMATION
Patient Name
Address
Contact Number
Alternate contact person and contact number (if applicable):
Does patient consent to being contacted by on the number/s above?
Does patient consent to a message (voicemail or SMS) being left on the above number/s?
Male
Female
Gender
Yes
Yes
No
No
Background
Patient Lives Alone
Main Language Spoken at Home
Aboriginal
Torres Strait Islander
Neither
Yes
No
Unknown
How well does the person speak English
Very Well
Well
Primary or Below
Highest Level of Education
English
Unknown
Other (describe):
Not Well
Not At All
Unknown
Primary-Year 10
Year 10
Year 11
Year 12
Tertiary
I have discussed with the patient/carer, and have gained consent for this information to be given to Marathon Health for the purpose of
facilitating this referral, receiving contact, and commencing treatment.
GP
Signature:________________________________
Patient / Parent Carer
Signature:__________________________
Date: ______________
Date of next review: _____________
Date: ______________
Important Information for GPs:
To refer into ATAPS, submit BOTH the completed referral form and Child Treatment Plan to the Marathon Health Centralised Intake team via:
secure fax: 02 6882 7224 or mentalhealthargus@marathonhealth.com.au
GPs should NOT send ATAPS referrals directly to Allied Health professionals - appointments should not be made until the ATAPS referral has been
accepted by Marathon Health.
ATAPS is a capped service and wait lists may apply
Submit via secure fax: 02 6882 7224 or to
mentalhealthargus@marathonhealth.com.au
GP Child Treatment Plan (for Clinical Services under ATAPS-CMHS)
(No MH diagnoses) Item 2713, Item 36 , Item 44
Date of Assessment:
General Practitioner:
Name:
Address:
Phone:
Provider No:
Post Code:
Fax:
Patient Details:
Tick if details are listed above
Name:
Address:
Phone:
Is this Child in Out of Home Care?
DOB:
Post Code:
Gender:
□Yes □No
□ Male □Female
Does the child communicate at an age-appropriate level?
Parent/Carer Contact Details:
Name:
Relationship:
Contact Phone:
Alternate Phone:
Preferred contact method:
PLEASE VERIFY CORRECT CONTACT DETAILS
General Assessment:
Presenting Problems: Provide a brief description of the child’s difficulties and reason/s for referral
(e.g. Psychological/emotional/behavioural/physical problems, learning difficulties, developmental
issues, social or peer issues, family difficulties/attachment, and/or other).
Medical and Developmental History: Provide a brief summary of the child’s previous physical and
mental health history including any previous diagnoses and developmental issues/delays.
Family Medical/ Mental Health History: List any serious physical or mental health conditions that
family members or relatives are known to have.
Current Medications and Allergies:
Risk Assessment: (If there is Immediate Significant risk please contact the 24hour Mental Health
Information and Support Service – 1800 011 511)
Risk of suicide
Yes □ No □
Risk of harm to others
Yes □ No □
Risk of self harm
Yes □ No □
Relevant Child Protection/Risk Information:
Other child protection concerns
Yes □ No □
Please provide further information relating to the areas of psychosocial functioning below:
Home and Family: List issues around living arrangements, number of siblings, changes of living,
custody issues, supervision etc.
Please call the Marathon Health Mental Health team on 02 6826 5271 for more information or visit
www.marathonhealth.com.au
Submit via secure fax: 02 6882 7224 or to
mentalhealthargus@marathonhealth.com.au
Learning Issues: Consider: Literacy and numeracy levels, attention/concentration, achievement of
potential.
Social/Behavioural Issues: Consider: Peer relationships, social skills, bullying, aggression,
attendance, conduct problems.
Eating, Exercise and Sleep: Consider: Nutrition, eating patterns, weight gain/loss, exercise, fitness,
energy, sleep.
Protective Factors/Personal Resources: Consider: Resilience, coping strategies, beliefs about self,
self-efficacy, spiritual/cultural beliefs, values, external supports.
Mental Status Examination
Appearance and General Behaviour
Mood (Depressed/ Labile)
□ Normal □ Other:
□ Normal □ Other:
Thinking (Content/Rate/Disturbances)
Affect (Flat/blunted)
□ Normal □ Other:
□ Normal □ Other:
Perception (Hallucinations etc.)
Sleep (Initial Insomnia/Early Morning Wakening)
□ Normal □ Other:
□ Normal □ Other:
Cognition (Level of
Appetite (Disturbed Eating Patterns)
Consciousness/Delirium/Intelligence)
□ Normal □ Other:
□ Normal □ Other:
Attention/Concentration
Motivation/Energy
□ Normal □ Other:
□ Normal □ Other:
Memory (Short and long Term)
Judgement (Ability to make rational decisions)
□ Normal □ Other:
□ Normal □ Other:
Insight
Anxiety Symptoms (Physical & Emotional)
□ Normal □ Other:
□ Normal □ Other:
Orientation (Time/Place/Person)
Speech (Volume/Rate/Content)
□ Normal □ Other:
□ Normal □ Other:
Outcome Tool Used:
Result/Score:
Problem(s)/ Action(s):
Problem:
Action:
I understand the above Treatment Plan and agree to the outlined actions for my child/child in
my care
Parent/Carer Signature:
GP Signature:
Please call the Marathon Health Mental Health team on 02 6826 5271 for more information or visit
www.marathonhealth.com.au
Submit via secure fax: 02 6882 7224 or to
mentalhealthargus@marathonhealth.com.au
Child Treatment Plan – REVIEW
1st Review Date:
Patient Name:
DOB:
GP:
Outcome Tool result on review:
Review Comments: (Progress on goals and actions outlined in Child Treatment Plan)
Other Relevant Information:
2nd Review Date:
Patient Name:
DOB:
GP:
Outcome Tool result on review:
Review Comments: (Progress on goals and actions outlined in Child Treatment Plan)
Other Relevant Information:
Please call the Marathon Health Mental Health team on 02 6826 5271 for more information or visit
www.marathonhealth.com.au
Submit via secure fax: 02 6882 7224 or to
mentalhealthargus@marathonhealth.com.au
Patient Referral - Information Sheet
GP to print and provide to patient
Access to Allied Psychological Services (ATAPS) and
Mental Health Services in Rural and Remote Areas (MHSRRA) programs
These projects are funded by the Commonwealth Department of Health and
facilitated via the Western NSW Primary Health Network and Marathon Health
Referral - Your GP has organised a referral following a Child Treatment Plan. Referral information
will be provided to the Marathon Health Mental Health Team.
Sessions – Up to 12 time-limited sessions (1 hour) are available, please see your GP for a review of
the Treatment Plan after 6 sessions, if further sessions are required
Who will contact you: You may be contacted by a member of the Marathon Health Mental Health
team if any more information is required to facilitate your referral.
Once the referral has been processed by Marathon Health, an ATAPS mental health provider will
contact you to arrange an appointment time
Access to Private Information - Your GP, the Marathon Health Mental Health Team and your
mental health provider will have access to information that is able to be identified with you/your child.
De-identified data (information with no names, addresses or contact details) will be collected by
Marathon Health Mental Health staff and stored in a secure data base.
This de-identified data will form part of the project report to the Department of Health.
You can contact Marathon Health on (02) 6826 5271 if you have any questions about this service.
ATAPS is not an urgent service and there may
be a wait time to access an initial appointment.
Please return to your GP, or see the contact numbers listed below
if you need additional support.
EMERGENCY NUMBERS
24 hr Mental Health Information and Support Service
Kids Help Line
Life Line
Parent Line
Emergency Services
1800 011 511
1800 551 800
13 11 14
1300 130 052
000
Date of next review with your GP: ___________________________
Please call the Marathon Health Mental Health team on 02 6826 5271 for more information or visit
www.marathonhealth.com.au