Medicare Mental Health Centre Liverpool Referral Form
Medicare Mental Health Centres provide free and confidential mental health support to adults aged 18 years and over. No Medicare card is required to access this service. Referral is not required but helpful.
Qualified mental health professionals including people with Lived Experience of mental health challenges work together to offer support to meet the needs of the person being referred. 
This may include:
•	Immediate mental health support for people in distress 
•	short or medium-term mental health and wellbeing support 
•	service navigation and helpful, relevant information.
Where consent is provided, referral outcomes may be shared with the person’s GP or referring provider.
Please note this is not an emergency service. If assessed at high risk of harm, call Triple Zero (000) or your local Public Mental Health Service.
For more information go to www.neaminational.org.au/Medicare-Mental-Health-Centre 
Referral details
Referral type (tick one)
General Practitioner
Psychiatrist
Obstetrician
Paediatrician
Other medical specialist 
Midwife
Maternal Health Nurse
Psychologist
Mental Health Nurse
Social Worker
Occupational Therapist
Aboriginal Health Worker
Educational Professional
Early Childhood Service Worker
Self-referral
Other (please specify):      
Referrer contact details
Name:      
Organisation:      
Phone:      
Fax:      
Email:      
Consumer details
Full name:      
Preferred name: 
Date of birth:      
Gender:      
Pronouns:      
Preferred contact method: 
☐	Phone
☐	SMS
☐	Email
Phone / mobile:      
Email:      
Interpreter required? 
☐	Yes
☐	No
Preferred language:      
Address:      
☐	No fixed address
Support needs & safety concerns 
Reason for referral (brief description)
Safety concerns (if applicable): 
☐	Suicidal thoughts/self-harm risk 
☐	Alcohol or drug-related concerns 
☐	Other (please describe):
Supporting Documentation (please provide with the referral, if available)
☐	Mental Health Treatment Plan (MHTP) 
•	Psychological distress assessment (K10/K5) 
•	IAR-DST assessment 
☐	Current medications & treatment 
☐	Relevant history (e.g. medical conditions, substance use)

Consent to share information 
The Privacy Act requires that the consumer provides consent for the disclosure of their information. By consenting to this referral, the consumer gives consent for the Medicare Mental Health Centre to collect and share information concerning matters related to this application, with the referrer, the referral support person outlined in this form, other service providers relevant to this referral and to sharing information with the Primary Health Network (PHN) that funds the service. The PHN uses this information for program management, quality improvement and monitoring service delivery. If the consumer also gives consent at the time of commencing support with the Medicare Mental Health Centre, some of their deidentified information may be shared with the Commonwealth Department of Health and Aged Care and state and territory health departments to be used for statistical and evaluation purposes to improve mental health services in Australia.
Consumer signature (guardian/parent if child):
☐	Or verbal consent (tick if applicable) 
Date:
The referrer agrees that all information submitted in this referral is an accurate reflection of the person's support needs, is correct with no information withheld, and is necessary for Medicare Mental Health Centres to fulfill their duty of care to service users, staff, and partner agencies.
Referrer signature:
Date:
Contact Details
Please return this referral form and any supporting documentation to Medicare Mental Health Centre Liverpool 
203 Northumberland Street, Liverpool, NSW, 2170 
Email: MedicareMHC.Liverpool@neaminational.org.au 
Fax: 02 8208 9982
Alternatively call 1800 004 424 to discuss the referral