Servicing people in the North Queensland Primary Health Network catchment area, Connect to Wellbeing provides an intake, triage and assessment service that facilitates access to the service(s) that best support the mental health needs of the individual.

Please user this referral form to recommend a level of service.

The Connect to Wellbeing clinical triage and intake team will review the referral, your recommendation and the client; and will determine the right level of intervention, according to their individual wants and needs.

Date of referral   <TodaysDate>                                     Services required for     <Services required for>

If the person has acute mental health needs, please refer to the Acute Care Team or Child Youth Mental Health Service via 1300 64 2255	
Please select your recommended service option for the person from the  following:

p	 Low Intensity Strategies
Psychological interventions for people with, or at risk of, mild mental illness. (As available can be individual, group, face to face, telephone, web-based supports).	

  p	Psychological Therapies
For low income / financially disadvantaged people with a non-acute moderate mental health condition who would
benefit from short-term goal focused psychological strategies

	Sessions required (select one of the below):	
  O	Sessions 1-6 (initial sessions), OR
	
  O	Sessions 7-10 (following review post the initial 6 sessions, further sessions are recommended), OR
	
O
	Sessions 11-16  exceptional circumstances apply (a psychiatrist's written recommendation must accompany this request).	
  O	or/and Group sessions (Groups will be advertised as available)
	
	Eligibility requires that (please tick):
	
p	A Mental Health Treatment Plan (MHTP) or Child Treatment Plan (CTP) is attached, OR Appendix A is completed AND
 	
p	The person has a Pension Card (aged or disability), Health Care Card or Low Income Health Care Card. 
	
	NB. Exceptions to the financial disadvantage requirement may apply for more information, refer to www.connecttowellbeing.org.au	

  p	Psychological Therapies in Residential Aged Care Facilties (RACFs)
For people with a non-acute mental health condition who would benefit from short-term goal focused psychological strategies	
	Eligibility requires that the person meets the following criteria:	
	•	The person resides in a Residential Aged Care Facility (RACF), AND	
	•	The person has a mental illness or is at risk of developing a mental illness.	

p	Suicide Prevention Services - Low to Moderate Suicide Risk
NOT intended to support people who are at acute and immediate risk.
	
	Where any of the following requirements are indicated, the person will be contacted within 24hrs (business days) of the date of referral and offered an appointment within 72hrs.	
	Sessions required (select one of the below):	
  O	Sessions 1-12 (initial sessions)	
	Please select at least one of the options below if the initial 12 sessions are required:	
p	After a suicide attempt or self-harm incident, the person has either been discharged from hospital into the care of a GP, or has been released into the care of a GP from an accident and emergency department.	
p	The person has presented to a GP after an incident of self-harm.	
p	The person has expressed recent ideation to their GP.	
  O	Sessions 13-18 (following review by GP within the 6-12 session window, further suggestions are recommended)	

p	Telehealth Specialist Services - Specialist video consultations under Medicare
The provision of a consultation via video conferencing by a consultant psychiatrist.
NB. The person must have access to a computer or tablet, with a webcam and speakers or headphones.
	
	Preferred location for the consultation (select one of the below):	
p	GP practice (the GP or another health professional may be at the patient-end of the consultation to provide clinical services where clinically appropriate).	
p	Client/patient home.	
p	Other (please describe): __________________________________________________________________	
	Additional requirements (tick if appropriate):	
p	The patient/client is experiencing financial difficulty (fees are waived where this is indicated).	
p	The patient/client understands they will be asked for credit card details and that a fee will be charged if an appointment that has been arranged is cancelled.

p	National Psychosocial Support Measure (NPSM)
Psychosocial support (for up to 12 months) for people with a severe episodic mental illness resulting in a reduced functional capacity.
	
	Eligibility requires that the person meets the following criteria:	
	•	Has a severe episodic mental illness resulting in reduced functional capacity.	
	•	Is not currently a client of public mental health services (QLD health), the NDIS or any other                    government-funded Mental health support programs (such as Cos, NPST, IRSP, GRSP).	
	•	Would benefit from less intensive, non-clinical, community-based psychosocial support.	
	•	Would benefit from peer connections or group support.	
	•	Is best supported in primary health care and is engaged with the primary health system (e.g.                  GP).	

p	Mental Health Integrated Complex Care (MHICC)
Providers longer term (up to 2 years) clinical support and treatment for individuals with severe mental illness with complex needs.
	
	Eligibility requires that the person meets the following criteria:	
	•	Has a severe episodic mental illness resulting in reduced functional capacity.	
	•	Consents to support/treatment from a Mental Health Nurse.	
	•	Is not a current client of public mental health services and is not receiving case                                        management through Queensland Health.	
	•	Has a current Mental Health Treatment Plan (MHTP) that identifies at least two or more                             aspects of their life as significantly impacted by mental illness (e.g. relationships, employment,                education, housing, community inclusion, physical health, etc).	
	•	Has experienced a hospitalisation for mental health issues in the past or is at risk of                                    hospitalisation if not supported.	
	•	Is best supported in primary health care and is engaged with a GP or psychiatrist who are                      principally responsible for their clinical mental health care.	

Referrer Details
				
Referrer name	<DrName>	Provider number	<DrProviderNo>	
Address	<DrAddress>			
Role/relationship
	<Role or Relationship to Consumer>	Email	<DrEmail>	
Phone
	<DrPhone>	Fax	<DrFax>	

Consumer Details				
Full name	<PtFullName>			
Preferred name	<Persons preferred name (if different)>	Date of Birth	<PtDoB>	
Gender	<PtSex>			
Street Address	<PtAddress>	No Fixed address	<No fixed address?>	
Suburb	<PtPOCity>	Postcode	<PtPostcode>	
Phone	<PtPhoneH>	Mobile	<PtPhoneMob>	
Email	<PtEmail>			
Preferred contact	<Preferred contact (multi-select)>	Voicemail?	<Ok to leave voicemail?>	
		Email?	<Ok to leave email?>	
Medicare Card	<PtMCNo>	Health Care card?	<PtInsFund>	
Pension?	<Does this person have a Pension card?>	Dept Veterans Affairs (DVA) Card?	<Does this person have a DVA card?>	
Proficiency in spoken English	<Proficiency in spoken English?>	Preferred Language	<Preferred Language>	
Interpreter required?	<Does this person require an interpreter?>			

Emergency Contact				
Primary contact	<NOKName>	Relationship/role	<NOKRelation>	
Agency	<Emergency contact Agency?>	Phone	<NOKContact>	
Email	<Emergency contact email address>			

Consent to share information 

The Privacy Act requires the applicant to sign this form giving their consent for the release of their information and details.

I, the consumer consent for Connect to Wellbeing to seek and share information concerning matters related to this application, with relevant Local Health District services, the emergency contact outlined in this form, and other service providers relevant to this referral.

Consumer Consent (or Guardian/Parent if a child) 	____________________________	Date	<TodaysDate>	
				
Referrer Acknowledgement	_____________________________	Date	<TodaysDate>	
The referrer agrees that all information submitted in this referral is an accurate reflection of the applicant’s support needs, is correct with no information withheld and is necessary for Connect to Wellbeing to fulfil its duty of care to consumers, staff and other partner agencies.

What happens now

Fax this referral with a Mental Health Treatment Plan and K10/K5/SDQ (as applicable) to Connect to Wellbeing.
Fax numbers: Cairns 07 4214 5225 | Townsville 07 4409 2304 | Mackay 07 4829 4424 OR
Refer via Medical Objects (Connect to Wellbeing - Cairns, Townsville or Mackay)	

A Connect to Wellbeing intake staff member will contact the person referred to validate the referral, and to schedule an appointment with a clinician to undertake an assessment.

 	

Contact

Phone 1300 020 390
www.connecttowellbeing.org.au

Connect to Wellbeing is a Neami National service supported by funding from the Australian Government under the PHN program.

APPENDIX A - Referral Information

(where MHTP/CTP does not provide this information)

	It is not necessary to complete Appendix A if a Mental Health Treatment Plan (MHTP) or Child Treatment Plan (CTP) accompanies this referral form and contains the information below.	

<Appendix A Section Below:>

Reason for referral (prospective of consumer and referrer)
<Reason for referral>

Perinatal <Perinatal>

Outcome measures (score) 
SDQ: <Outcome score SDQ> K10:<Outcome score K10> K5: <Outcome score K5>

Mental health diagnosis (if known / symptoms (or at risk of developing mental illness if child under 12)
<Mental health diagnosis (if known)/symptoms>

Medication
<SelectedRx>

Substance Use
<Substance use>

Other relevant history/factors (eg. climatic events, disabilities, medical conditions, allergies)
<Other relevant history/factors>

Risk (describe if risk to self, if risk to others)
<Describe if there is risk to self or others>

Health professionals involved in consumer's care (eg GP, allied health professional, psychiatrist)
<Other involved in persons care?>

Please attach any other relevant information or assessments if applicable/appropriate.