Referral Options
    A - Darwin Adult Head to Health Centre – 16 Scaturchio Street, Casuarina
Adults within the Greater Darwin region are able to present in person to the Adult HtH Centre

Please select what kind of support is needed (insert an 'X' in the relevant boxes below)
	Option 1 - Support for mental health distress or crisis (follow up within 24 hours including weekends)	
	Option 2 - Ongoing support or service navigation (follow up within 7 days)	

B - Short Term Therapies (STT) Program
	B1: STT - Psychological Therapies (PT) Stream - Eligibility Criteria (all ages)	

*One of the following is required:
	A Mental Health Treatment Plan (MHTP) OR	
	Completed Appendix A - for provisional referrals if no MHTP is available	
Note that a MHTP is still required within 4 weeks for provisional referrals – see STT program specifications for further details
*One of the following applies:
	The consumer holds a current Health Care Card, Low income Health Care Card, or Pension Card	
Please note, if consumer is dependent and under 18, low income is based on their parents and/or caregiver’s circumstances.
	The consumer is experiencing exceptional financial hardship	
 Provide rationale in the reason for referral Section below (for example, has recently lost employment or is experiencing domestic violence and is unable to access bank accounts). Please note, that low income/financial hardship is an essential part of eligibility.
	B2: Suicide Prevention (SP Stream)	
Immediate and intensive therapy to individuals during a period of increased risk of suicide for a period of up to 3 months. This service is designed for 3 distinct groups: (1) - individuals who, after a suicide attempt have been discharged into the care of a GP, (2) - individuals that have expressed strong suicidal ideation or (3) - individuals who are considered at increased risk in the aftermath of suicide.
Please note the consumer will be contacted by the end of the next business day and offered support and an appointment within 72 hrs of referral.

C – Telehealth Specialist Services*
Specialist video consultation under Medicare. Please select what kind of support is needed:
	Initial video - Consultation with a consultant psychiatrist: Medicare Bulk billed (291) 	
	Specialist video consultations - Psychiatric review of plan provided under Medicare (293)	

*Referrals must be made by GP or nurse practitioner only and can be in addition to other services. Please note the client will be charged a fee if the arranged appointment is canceled/not attended.

Reason for referral:
<<Reason for referral>>

If you have uitilised the Initial Assessment & Referral Decision Support Tool (IAR-DST) online  https://iar-dst.online/#/, please attach a copy of the report to this referral

Referrer Details
Referrer name: <<Miscellaneous:Current User>>   Role / Organisation: <<Practice/Location:Name>>
Address:  <<Doctor:Full Address>>                             
Phone: <<Doctor:Phone>>           Fax: <<Doctor:Fax>>        *Email: <<Doctor:E-mail>>
*To receive notification that this referral has been allocated, email address is required

Consumer Details
Full name: <<Patient Demographics:Full Name>>       Preferred name : <<Patient Preferred Name>> 
DOB: <<Patient Demographics:DOB>>                          Gender : <<Patient Demographics:Gender>>	 Pronouns: <<Pronouns>>   Marital Status: <<Patient Demographics:Marital Status>> 
Country of birth: <<Patient Demographics:Country of Birth>>
Address: <<Patient Demographics:Full Address>>	 
No fixed address: <<No fixed Address>>      Mobile: <<Patient Demographics:Phone (Mobile)>>      Email: <<Patient Demographics:E-mail>> 
Preferred contact mode/time/day:  <<Preferred contact mode/time/day>>
Languages spoken at home: <<Patient Demographics:Language Spoken>>         Interpreter required? <<Patient Demographics:Requires Interpreter>>
Employment/Income Status
	Full time		Part time/Casual		 Nil income		 Unemployed		Other	
	NDIS participant		Disability Pension		DVA		Compensation 
payments			
Indigenous Status
	Aboriginal		Torres Strait Islander		Aboriginal & Torres Strait Islander		Neither	
Eligible for Medicare?	<<Eligible for Medicare?>>      Medicare number: <<Patient Demographics:Medicare Number>>
Referral Support Person
Contact if the consumer is unavailable. If the consumer is a child, provide the details of the responsible parent or guardian.
Relationship/role:  <<Support person relationship/role>>            Full name: <<Support person - full name>>
Agency: <<Agency>>         Phone: <<Support person phone>>           Email: <<Email>>
Consent to Share Information
The Privacy Act requires that the consumer sign this form to provide consent for the release of their information. By signing below, the consumer gives consent for Head to Health Darwin to seek and share information concerning matters related to this application, with the Northern Territory PHN, the referral support person outlined in this form, and other service providers relevant to this referral. The consumer also gives consent to their information being used for statistical and evaluation purposes to improve mental health services in Australia. They understand that this will include details about them such as date of birth, gender and types of services they use, but will not include their name, address or Medicare/Pension/Health Care Card numbers.
Consumer signature: _____________________________Guardian/parent if child		Or verbal consent
Tick if applicable	Date: <<Miscellaneous:Date>>	
Referrer signature: ________________________________			Date: <<Miscellaneous:Date>>	

The referrer agrees that all information submitted in this referral is an accurate reflection of the consumer’s support needs and is correct with no information withheld, so Head to Health can fulfill its duty of care to consumers, staff, and other partner agencies.

What happens now?
Send this referral with a Mental Health Treatment Plan to Head to Health:
•	Phone 1800 844 054
•	Email HEADTOHEALTHNT@neaminational.org.au
•	Fax on 08 7906 2260
•	Medical Objects HEAD TO HEALTH NT (TH0820000A0)

Appendix A - Additional Referral Information

	It is not necessary to complete Appendix A if a Mental Health Treatment Plan (MHTP) accompanies this referral form. Please note a MHTP is still required within four weeks of referral.
Health services, Allied Health professionals and community services can complete Appendix A	

Perinatal: <<Perinatal>>

Outcome measures	SDQ score		K10 score		K5 score		

Mental health diagnosis:
(Diagnosis and symptoms if known. Or risk of developing mental illness if under 12 years old)	<<Mental health diagnosis>>	
Medication:	<<Medication>>	
Substance use:	<<Substance Use>>	

Relevant history: (Other relevant history/ factors such as climatic events, disabilities, medical conditions etc.)	<<Relevant History>>	
Risk:
(Describe if risk to self or others.)	<<Risk (describe if risk to self or others)>>	
Care team:
(Health professionals involved in person's care
i.e. GP, psychiatrist.)	<<Careteam members>>