BHS SMART GP MENTAL HEALTH REFERRAL
Referral date: Miscellaneous.Date
Referral time:Miscellaneous.Time
	Version 1
( ZM 2020)	

REFERRED BY
Name: Treating Doctor.Name
Practice: Practice.Name
Address: Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Provider #: Treating Doctor.Provider Number

	PATIENT DETAILS
Name: Patient Demographics.Full Name
Gender: Patient Demographics.Gender
DOB: Patient Demographics.DOB
Address: Patient Demographics.Address Patient Demographics.Suburb
Home ph: Patient Demographics.Phone (Home)
Mobile: Patient Demographics.Phone (Mobile)
Medicare #: Patient Demographics.Medicare Number
Pension: Patient Demographics.Pension Number
DVA #: Patient Demographics.DVA Number
ATSI: ATSI
Interpreter required: Interpreter2 
Next of Kin: Patient Demographics.NOK Home Phone 
Patient Demographics.NOK Mobile Phone	
PATIENT CONSENT

Patient consents to sharing medical information: Consent 
Is patient aware of referral? Patient aware of ref	
MENTAL HEALTH SERVICE REQUIRED - fax referral to 5320 4028: Service requested
	
REFERRAL DETAILS:

Are you the patient's usual GP: UsualGP
If not, name of usual GP: Name of Usual GP
How long have you known this patient?: How long known pt	
REASON FOR REFERRAL & PRESENTING PROBLEM

History 	
SPECIAL ALERTS:

Allergies: Clinical Details.Allergies
Smoking status: Clinical Details.Smoking
Alcohol history: Clinical Details.Alcohol (Summary)
Current pregnancy: Pregnancy.Current Gestational DatesPregnancy.EDC	
RISK ISSUES:

Is the patient homeless: Homeless
Risk of suicide: Any risk of suicide?
If yes, please provide details: Suicidal
Is the patient at risk of harm to themselves or others?: Risk of harm
If, yes, please provide details: Risk of harm
Any drug or alcohol issues?: Drug or alcohol risk
If yes, please explain: Drug or alcohol issu
Any history of violent or aggressive behaviours? :Aggressive behaviour
Is the patient displaying psychotic symptoms?: Psychotic symptoms
If yes, please explain: Psychotic symptoms
Any evidence of eating disorders?: Eating disorders 	
OTHER HEALTH PROFESSIONALS/SERVICES INVOLVED

Has the patient been admitted at any other hospital for a mental health condition?: Previous admission
If yes, where and what year (if known): Previous admission
Is the patient under the care of any other health providers?: Other health provide
List names of any treating Psychiatrist or Psychologist: Other providers	
PROGRESS NOTES
Clinical Details.Selectable Encounter Notes	
PAST MEDICAL HISTORY (including psychiatric history)

Clinical Details.Problem List (Current)
Clinical Details.Problem List (Resolved)	
FAMILY & SOCIAL HISTORY

Clinical Details.Social History
Clinical Details.Family History	
CURRENT MEDICATIONS

Clinical Details.Medication List	
LIVING ARRANGEMENTS

Lives alone?: Lives alone
Has a carer?: Has a carer
	
 INVESTIGATION RESULTS:

Clinical Details.Result List (Selected)