REQUEST FOR MENTAL HEALTH SERVICES		

GP Referral
		Referral Date: <<Miscellaneous:Date (long)>>

Feedback Requested:  Yes	

Referral to:
Healthfocus Clinical Psychology Services

Armadale: 
Shop 6 Pioneer Village Complex
7 Albany Highway, Mt Richon WA 6112

Riverton: 
Unit 1, 2 Madeira Road, Parkwood WA 6147

Service requested: <<Service Requested:>>

Urgency:  <<Urgency>>
Referral vaid for:  <<Referral valid for>>		Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
<<Practice:Address>>
<<Practice:HPI-O>>
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>
HPI-I<<Doctor:HPI-I>>	

Consumer details:
Name:	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth:	<<Patient Demographics:DOB>>
Age:                        <<Patient Demographics:Age>>
Preferred Name/s:	<<Patient Demographics:Greeting>>
Sex:	<<Patient Demographics:Sex>>
Title:	<<Patient Demographics:Title>>
IHI:                          <<Patient Demographics:IHI>>
		Contact Address:	<<Patient Demographics:Full Name>>
	<<Patient Demographics:Address>>
<<Patient Demographics:City>>  <<Patient Demographics:State>>    <<Patient Demographics:Postcode>>
Phone:	<<Patient Demographics:Phone (Home)>>
Work:	<<Patient Demographics:Phone (Work)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>
Email:	<<Patient Demographics:E-mail>>

Alternative Contact: 
<<Alternative Contact (Name/Ph/Relationship)>>
Next of Kin:
<<Next of Kin (Name/Ph/Relationship)>>
Legal status:
<<Legal Status>>
Patient has been made subject of a Compulsory Assessment Order: <<Pt made the subject of a compulsory Ax order?>>	

Interpreter required: <<Does the patient require an interpreter?>>		DVA Number: <<Patient Demographics:DVA Number>>	
Preferred language is: <<If interpreter needed, which language>>		Insurance: <<Patient Demographics:Health Insurance>>	
Pension Card Number: <<Patient Demographics:Pension Number>>		Medicare Number: <<Patient Demographics:Medicare Number>>	

Clinical Information:	 

Reason for patient referral: 
<<Reason for Referral>>
Functional Status:
Mental Health Care Plan undertaken:  <<Mental Health Care Plan undertaken?>>
MMSE:  <<MMSE>>  
Living arrangements:<<Living arrangements?>>  
Accommodation setting:<<Accommodation setting?>>
Current case management details:
<<Current case management details?>>
Recent specialist or service referrals:  
<<Recent specialist or service referrals>>
Recent hospital admissions: 
<<Recent hospital admissions?>>

Warnings: 
<<Clinical Details:Warnings>>

Allergies: 
<<Clinical Details:Allergies>> 
Current Medication:
<<Clinical Details:Medication List>>
Social History: 
<<Clinical Details:Social History>> 
<<Clinical Details:Smoking>>
Past Medical History: 
<<Clinical Details:History List>>
 ---------------------------------------------------------------------------------------------------------------------------------
Progress Notes: 
<<Summary:Progress Notes (Selected)>>

Investigation Results:
<<Summary:Investigation Results (Selected)>>

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>>  DOB:  <<Patient Demographics:DOB>>