Forward completed Referral via Medical Objects ID : HEALTH GOLD COAST REFERRALS, HEAD (RG4220000HJ)

REFERRAL FORM - Medicare Mental Health Phone Service

Servicing people in the Gold Coast PHN area. Medicare Mental Health Phone Service provides a free, confidential referral service for anyone seeking help for their wellbeing or wanting support for a patient or someone they care about. If the person has acute mental health needs, refer to MH Call on 1300 64 22 55.

If you have completed a Mental Health Treatment Plan (MHTP) or used the Initial Assessment and Referral Decision Support Tool please attach with the referral.

Consent to share information

By consenting to this referral, the person is consenting to the sharing of their personal information. The information contained in the referral is used by the Medicare Mental Health Phone Service to:
(1) deliver assessment and referral services
(2) for monitoring, aggregate reporting and evaluation purposes to improve quality and access to care.
This information will be passed on to the recommended provider who will contact the person.

Please indicate the information in this form has been discussed with, and provided to, the patient.  <Indicate this info has been discussed and provided to patient>

Patient or Parent/Guardian/Carer consents to Referral  <Patient or Parent/Guardian/Carer consents to referral>

Referrer consents to the collection and storage of referrer details on internal database  <Referrer consents to collection and storage of referrer details on internal database>

Referral Date  <TodaysDate>

REFERRER DETAILS

Referrer's role	<Referrer's role>	
Referrer's name	<DrName>	
Referrer's email	<DrEmail>	
Practice name	<Practice>	
Practice address	<UsrAddress>	
Practice phone no	<UsrPhone>	
Practice fax no	<UsrFax>	

PATIENT DETAILS	

RE:  <PtDetails>  	DOB: <PtDoB>  	
Gender  <PtSex>
Pronoun <Pronoun>	Other gender identity (if applicable)  <Patient - Other Gender Identity (if applicable)>	
Address   <PtAddress>	Experiencing homelessness  <Experiencing homelessness>	
Home phone no  <PtPhoneH>  	Mobile phone no  <PtPhoneMob>	
Email <PtEmail>	 Interpreter required  <Is an interpreter required>
Language <Language>	
Emergency Contact name  <Emergency Contact Name>	Relationship <Emergency Contact relationship>	
Phone number  <Emergency Contact phone number>		

REFERRAL NOTES

Any additional information that may support the consumer and this referral:

<Referral Notes: Any additional information to support this referral>