Medicare Mental Health Intake Referral Form

IMPORTANT

Medicare Mental Health supports people of all ages to access tailored mental health advice and service options.

If you’re a healthcare provider or other professional referring someone to the IAR service, please complete the form below.

You’ll need to confirm that you have obtained the person’s consent to share their personal information.

All information submitted via this form is securely stored and managed in line with Country to Coast Queensland PHN privacy policy

Important: Safe contact considerations

If your client may be at risk from receiving an unexpected phone call (e.g. those experiencing domestic and family violence), please consider whether it is preferrable for them to call 1800 595 212 directly.

If you are an individual seeking support, please call 1800 595 212 (operating 8.30am to 5pm Monday to Friday) or visit a Medicare Mental Health Centre.

Medicare Mental Health is not a crisis service. Contact your Local Acute Care Team on 1300 642255 (1300 MHCALL) or if this is an emergency, please call Triple Zero (000)

Medicare Mental Health services are funded locally through their PHN Program. Medicare Mental Health and the PHN Program are Australian Government initiatives.

ORGANISATION DETAILS

Organisation type

Select your Hospital and Health Service

Select your PHN commissioned service provider

Enter name of organisation to search and select

GpOrg_SearchResult

Can't find my practice

Organisation

Email address

Mobile phone

REFERRER DETAILS

Referrer name

Role

Referrer phone

CONSENT

I confirm that consent has been obtained in accordance with the Privacy Act 1988 (Cth) and the consumer has provided consent for their anonymised data to be used for evaluation and planning purposes by the Department of Health, Disability and Aged Care.

CLIENT (PATIENT) DETAILS

First name

Last name

Preferred name

Date of birth

Gender

Indigenous status

Preferred language other than English

Interpreter required

NoYes

REASON FOR REFERRAL

RISK ASSESSMENT

Suicidality

Self-harm

Risk of harm to others

If high risk or greater in any category, please add comments below and consider if this referral is more suitable to the Acute Care Team

CLIENT (PATIENT) CONTACT DETAILS

Residential address

Residential suburb

Residential postcode

Residential state

Client mobile

Client home

Client email

CLIENT'S (PATIENT'S) COMMUNICATION PREFERENCE

ALTERNATIVE CONTACT PERSON

First name

Last name

Phone number

Relationship to patient

Notes

CLIENT (PATIENT) MEDICAL INFORMATION

Current medication

Relevant co-morbidity / medical history

CLIENT (PATIENT) DEMOGRAPHICS INFORMATION

Employment

Source of income

Culturally and linguistically diverse (CALD)

Domestic/family violence

Homelessness

NDIS and support coordination

ADDITIONAL INFORMATION & ATTACHMENTS

Any other relevant information

Attachments

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