REQUEST FOR MENTAL HEALTH, DRUG & ALCOHOL SERVICES
E-refer via ReferralNet (BH.Mental.Health)
FAX:  03 4215 2590
			
GP Referral		Referral Date: Miscellaneous.Date
Feedback Requested:  Feedback requested	

Referral to:
Barwon Health Mental Health, Drug & Alcohol Services

Phone: MHDAS TRIAGE 1300 094 187
Fax: 03 4215 2590

Referral Urgency: Referral Urgency
Referral valid for: Referral valid for		Referring General Practitioner:
Name:Treating Doctor.Name
Practice: Practice.Name
Address:Practice.Address
Phone:  Practice.Phone
Fax:  Practice.Fax
Email: Treating Doctor.E-mail
Provider No.: Treating Doctor.Provider Number	

Patient/Client/Consumer details:
Title: Patient Demographics.Title
First name: Patient Demographics.First Name
Surname: Patient Demographics.Surname
Preferred Name: Patient Demographics.Popular Name

Date of Birth: Patient Demographics.DOB          Age: Patient Demographics.Age
Gender: Patient Demographics.Gender 

ATSI: Patient Demographics.ATSI Status
Interpreter required: Interpreter
Preferred language is: Preferred language
Please consider Telehealth for this patient: Telehealth 
Cultural safety requirements: Cultural Safety
Access/Support requirements: Access/Support

Client has been made subject of a Compulsory Assessment Order:
Compulsory Ax Order
		Address: Patient Demographics.Full Address
Mobile: Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Home Phone: Patient Demographics.Phone (Home)
Work Phone: Patient Demographics.Phone (Work)
Preferred method of communication: Preferred contact 

Medicare: Patient Demographics.Medicare Number  Expiry: Patient Demographics.Medicare Expiry Date
Pension/HCC: Patient Demographics.Pension Number
DVA: Patient Demographics.DVA Number
Insurance: Patient Demographics.Health Fund NamePatient Demographics.Health Fund Member Number

Alternate contact person:
Alternate contact person name: Alternate contact 
Alternate contact person relationship: Relationship
Alternate contact person details: Alternate contact-ph	

Consent to referral: Consent to referral
Consent to share information: Consent- information
Is this a 2nd referral for the same problem: 2nd referral?
Usual GP (if not referrer):  Usual GP	

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways	

Reason for referral:
Reason for referral

Mental Health Care Plan undertaken:  MH Care Plan
MMSE:  MMSE
Living arrangements:  Living arrangements
Accommodation setting:  Accommodation

Current care details (case management details, recent services/specialist care/hospitalisations): 
Current care details

Past Medical History: 
Clinical Details.Past History

Social History:
Clinical Details.Social History

Family History:
Clinical Details.Family History

Alcohol history:  
Clinical Details.Alcohol

Smoking status: Clinical Details.Social History
If smoker, smoking cessation discussed:  Smoking cessation

Current Medication:
Clinical Details.Medications - Current Regular
 
Alerts:
Clinical Details.Warnings

Allergies: 
Clinical Details.Allergies

Electronically signed: Treating Doctor.Name