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

RE: <<Patient Demographics:Full Name>> | DOB: <<Patient Demographics:DOB>>

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: <<Miscellaneous:Date (short)>> 

REFERRER DETAILS
Referrer's name | <<Doctor:Name>>
Referrer's email | <<Doctor:E-mail>>
Practice name | <<Practice:Name>>
Practice address | <<Practice:Address>>
Practice phone no | <<Practice:Phone>>
Practice fax no | <<Practice:Fax>>
Provider no | <<Doctor:Provider Number>>
Preferred method of contact (if required) | <<GP: Preferred method of contact (if required)>>
If other, please advise | <<If other, please advise>>

PATIENT DETAILS

Address | <<Patient Demographics:Full Address>>
Home phone number | <<Patient Demographics:Phone (Home)>>
Mobile phone number | <<Patient Demographics:Phone (Mobile)>>
Preferred method of contact | <<Patient: Preferred method of contact>>
Consent: The patient consents to PCCS contacting them and receiving/sharing relevant information for this request | <<Pt 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 pt's mental health issues/access to 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 MH 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>>

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, day program, hosp option>>

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 for things affecting MH>>

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 MH: Housing/homelessness/unsafe>>
Family, relationship, parenting or carer stress | <<Affecting MH: Family/relationship/parenting>>
Family violence, AVO, legal or safeguarding concerns | <<Affection MH: Family violence/AVO/legal>>
Financial stress, Centrelink, debt or benefits issues | <<Affecting MH: Financial stress/Centrelink/debt>>
Employment, education, volunteering or study needs | <<Affecting MH: Employment/education/volunteering>>
Social isolation, loneliness or loss of connection | <<Affecting MH: Social isolation/loneliness>>
Cultural, language, settlement or community connection needs | <<Affecting MH: Cultural/language/settlement>>
Transport, technology, appointment access or communication barriers | <<Affecting MH: Transport/technology/access>>
Disability, long-term health condition or service navigation needs | <<Affecting MH: Disability/long term health condition>>
Recent hospitalisation, discharge planning or aftercare needs | <<Affecting MH: Hospitalisation/discharge/after care>>
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/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: <<Patient Demographics:Full Name>> DOB: <<Patient Demographics:DOB>>         Developed by Gold Coast Primary Health Network	     Version V1 August 2026