Aged Care Access Initiative ~ Psychological Services
Patient Referral
Patient Name:
Present Address:
DOB:
Gender:
Date of referral:
Primary GP Name:
Contact number:
Contact Fax:
Presenting Problem/Diagnosis
Number 1:
Number 2:
Number 3:
Medications
Past History
Mental Health History/Treatment
Has the person ever received specialist mental health care?
Other Relevant Information:
Ethnicity:
Primary language spoken:
Family History
Are there family members/carers who may benefit from being involved in this service?
Yes
If yes,
Name:
Contact Number:
Medical History
No
Relevant Physical and Mental Examination
Relevant Investigations
Mental Status Examination
Appearance and General Behaviour
Mood (Depressed/Labile)
 Normal
 Normal

Other:
Thinking (Content/Rate/Disturbances)
 Normal
 Other:
Affect (Flat/blunted)
 Other:
 Normal
 Other:
Perception (Hallucinations etc.)
Sleep (Initial Insomnia/Early Morning Wakening)
 Normal

 Normal

 Normal

 Normal
 Other:
Other:
Cognition (Level of Consciousness/Delirium/Intelligence)
Other:
Appetite (Disturbed Eating Patterns)
Other:
Attention/Concentration
Motivation/Energy
 Normal

 Normal

 Normal
 Other:
 Normal

 Normal

 Normal

 Normal
 Other:
 Normal
 Other:
Other:
Memory (Short and Long Term)
Other:
Judgment (Ability to make rational decisions)
Other:
Anxiety Symptoms (Physical & Emotional)
Insight
Other:
Orientation (Time/Place/Person)
Other:
Speech (Volume/Rate/Content)
Risk Assessment
Suicidal Ideation
Suicidal Intent
Current Plan
Risk to Others
Other Mental Health Professionals Involved in Patient Care
Name/Profession:
Contact Number:
Record of Patient Consent
I,
, (patient name - please print clearly)
Consent to this Care Plan to proceed and I agree to information about my mental health being recorded in my medical file and being
shared between the GP and the counsellor(s) to whom I am referred, to assist in the management of my health care.
Signature (patient):
Date:
Please complete and fax to the MGPN Secure Referral Management Centre
on 9348 0750