Forward completed Referral via Medical Objects to 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.  Info discussed pt

Patient or Parent/Guardian/Carer consents to Referral Patient Consent

Referrer consents to the collection and storage of referrer details on internal database  Referrer's Consent

Referral Date  Miscellaneous.Date

REFERRER DETAILS

Referrer's role	Referrer's Role	
Referrer's name	Treating Doctor.Name	
Referrer's email	Treating Doctor.E-mail	
Practice name	Practice.Name	
Practice address	Practice.Address	
Practice phone no	Practice.Phone	
Practice fax no	Practice.Fax	

PATIENT DETAILS

RE: Patient Demographics.Full Name	DOB: Patient Demographics.DOB	
Gender  Patient Demographics.Gender
Pronoun  Pronoun	Other gender identity (if applicable)  Other Gender	
Address Patient Demographics.Address	Experiencing homelessness Homelessness	
Home phone Patient Demographics.Phone (Home)	Mobile phone Patient Demographics.Phone (Mobile)	
Email Patient Demographics.E-mail	Is an interpreter required  Interpreter	
	Language  Language	
Emergency contact name  EC Name	Emergency contact relationship EC relationship	
Emergency contact phone number  EC Phone		

REFERRAL NOTES

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

 Referral Notes