PCCS Medicare Mental Health
GP Assist: Referral and Navigation Request

Forward completed Referral via Medical Objects to:
MENTAL HEALTH GOLD COAST REFERRAL, MEDICARE (RG4220000HJ)
For more information call 07 3186 4000

RE:  <PtDetails> | DOB: <PtDoB>

A GP handover document to allow us to help the patient find the right next step across psychology, mental health, psychosocial, community and social prescribing pathways.

**Urgent or immediate risk: This referral is not for emergency or crisis response. If there is immediate risk of harm, psychosis, severe disorganisation, or urgent safeguarding concern, use emergency/crisis pathways first, including 000, local acute mental health services, or the Mental Health Access Line as locally appropriate.

Referral Date  <TodaysDate>

REFERRER DETAILS

Referrer's name | <DrName>
Referrer's email | <DrEmail>
Practice name | <Practice>
Practice address | <UsrAddress>
Practice phone no | <UsrPhone>
Practice fax no | <UsrFax>
Provider  no | <DrProviderNo>
Preferred method of contact (if required) | <Preferred method of contact (GP)>
If other, please advise | <If other, please advise>

PATIENT DETAILS

Address | <PtAddress>
Home phone number | <PtPhoneH>
Mobile phone number | <PtPhoneMob>
Preferred method of contact | <Preferred method of contact (patient)>
Consent: The patient consents to PCCS contacting them and receiving/sharing relevant information for this request | <Patient consents to contact by/data sharing with PCCS>

PATIENT CONCERNS AND SUPPORT REQUIRED

Please briefly describe what you would like help with, including the main issues affecting the patient's mental health or ability to access care.

<Describe patient's mental health issues and ability to access care>

What type of support are you seeking? (Select all that apply)

Low intensity or early support
Brief, preventative or low-intensity support, such as Medicare Mental Health Check In, digital support, brief coaching, information, advice or supported self-management

<Support required: Low intensity or early support>

Moderate-intensity mental health care
Psychology, counselling, Better Access, psychosocial support, skills-building or other structured mental health support.
NB: Please attach MHTP, referral letter or clinical summary where available

<Support required: Moderate-intensity mental health care>

Higher-intensity mental health care
Care coordination, suicide aftercare, AOD support, discharge support, multidisciplinary care or connection with specialist/community mental health pathways.

<Support required: Higher-intensity or complex support>

Private health, day program or hospital-based options
Help exploring private health-funded services, day programs, outpatient groups, inpatient programs or other structured private options.
NB: Please attach private health details, referral letter, MHTP, discharge summary or relevant clinical information where available.

<Support required: Private health, day program or hospital-based options>

Care and supports for things affecting mental health
Help with social, practical or contextual issues affecting stress, anxiety, mood, distress, functioning or access to care.

<Support required: Care and supports for things affecting mental health>

Not sure what fits best
We can contact the patient, clarify what they need and advise you on possible next steps

<Support required: Not sure what fits best>

Care and supports for things affecting mental health
Select any issues affecting the patient's stress, anxiety, mood, distress, functioning or ability to access care

Housing, homelessness or unsafe accommodation | <Affecting mental health: Housing, homelessness, unsafe accommodation>
Family, relationship, parenting or carer stress | <Affecting mental health: Family/relationship/parenting/carer stress>
Family violence, AVO, legal or safeguarding concerns | <Affecting mental health: Family violence/AVO/legal/safeguarding>
Financial stress, Centrelink, debt or benefits issues | <Affecting mental health: Financial stress/Centrelink/debt>
Employment, education, volunteering or study needs | <Affecting mental health:  Employment/education/volunteering>
Social isolation, loneliness or loss of connection | <Affecting mental health: Social isolation/loneliness>
Cultural, language, settlement or community connection needs | <Affecting mental health: Cultural/language/settlement>
Transport, technology, appointment access or communication barriers | <Affecting mental health: Transport/technology/access>
Disability, long-term health condition or service navigation needs | <Affecting mental health: Disability/long term health condition>
Recent hospitalisation, discharge planning or aftercare needs | <Affecting mental health: Hospitalisation/discharge/aftercare>
Practical skills, routines, confidence or daily life support | <Affecting mental health:Practical skills/confidence>
Groups, activities, community participation or social prescribing support | <Affecting mental health: Groups/activities/community>
Other: | <If other, please describe>

Send relevant documents separately

Private health details, referral letters, MHTP, discharge summary or relevant clinical information sent separately where relevant and available. <Referral letters and/or relevant docs sent separately>

NB:  Create a new message in Medical Objects - PDF option

What we will do

• Acknowledge your request
• Contact the patient
• Connect the patient to appropriate services and support
• Provide you a discharge summary
• Communicate with you if we face any difficulties contacting or assisting the patient

Patient Name: <PtFullName>	DOB: <PtDoB>					Developed by Gold Coast Primary Health Network			     Version 1.0  August 2026