Head to Health Intake Referral Form

IMPORTANT

I understand that Head to Health is NOT a crisis service. Patients in crisis should be referred to the local Acute Care Team or dial 000 in an emergency.
Our operating hours are Monday to Friday 8.30am-5.00pm.
Patients can self-refer by calling Head to Health directly on 1800 595 212 and will be assessed, where appropriate, using the Initial Assessment and Referral Decision Support Tool (IAR-DST)
For patients at risk of accepting a random call from Head to Health (e.g., those experiencing DFV), consider asking the client to call Head to Health directly.
For diagnostic and management advice, call the GP Psychiatry Support Line on 1800 161 718.

Health Pathways

For more information on HealthPathways in Central Queensland, Wide Bay & Sunshine Coast, please link here

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 acknowledge that I have read and provide consent

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

Generate a new image Play the audio code

Enter the code from the image