SERVICE PROVIDER GPH MENTAL HEALTH AND ALCOHOL AND OTHER DRUG PROGRAMS e- REFERRAL FORM

This form is for GPs and Service Providers only. Alternatively, consumers and parents or caregivers can refer themselves using our self-referral e-form. Note, at GPH we use the term consumer to refer to the children, young people, adults and families and carers that use our mental health, suicide prevention and alcohol and other drug services.

REFERRER

Name

Profession

Organisation

Address

Phone

CONSUMER

Please note that all GPH Mental health and alcohol and other drug programs are voluntary. We will not accept referrals without the consumer's (or their parent/caregiver’s) consent. Is the consumer (or their parent/caregiver) aware of and has agreed to a referral to GPH?

Yes No

First Names*

Surname*

DOB*

Day

Month

Year

Preferred Name

What pronoun do they use?

For example: she/her, he/his, they/them
Learn more about pronouns : QHRC : Why pronouns matter.

Mobile

Please enter 10 digital number without spaces (e.g. 0499888888).

Home Phone

Please include area code without spaces (e.g. 0299998888).

Address

Address*

Suburb*

State*

Postcode*

Emergency Contact

Name*

Phone*

If not a mobile, please include area code without spaces (e.g. 0299998888).

Preferred Language

Do they require an interpreter?

Yes No

MENTAL HEALTH and SUBSTANCE USE INFORMATION

HARM

If the consumer is currently experiencing an acute risk of harm or suicidal crisis needing immediate and acute services, please contact the Mental Health Line on
1800 011 511 or Emergency Services on triple zero (000).

FUNCTIONING

IMPACT OF CO-EXISTING CONDITIONS

SOCIAL AND ENVIRONMENTAL STRESSORS

FAMILY AND OTHER SUPPORTS

ENGAGEMENT AND MOTIVATION

In addition, GP’s requesting services via a mental health treatment plan (MHTP) are to email/fax the MHTP directly to the relevant program. Contact details of all our programs can be found at https://www.gph.org.au/services/mental-health/.

Note that our referral forms are based on the Australian Government Initial Assessment and Referral Decision Support Tool (IAR-DST) domains for mental health. GPH mental health programs use this tool to gather initial information and determine suitability. Completing this referral form is different from the initial assessment we will undertake. The scoring utilised is to simplify the referral process and will not impact service delivery.

The relevant program will acknowledge and process your referral as soon as possible.