Non-Urgent Mental Health Service Referral Form
For response time greater than 24 hrs
Last name: <PtSurname>	Given name: <PtFirstName>	URN:	
DOB: <PtDoB>	Male/Female/Other: <PtSex>	Indigenous Australian: <Indigenous Australian>	
Language spoken: <Language spoken>	Interpreter required: <Interpreter required>		
Address: 	<PtAddress>	Ph: <PtPhoneMob>	
Diagnosis: 	<Diagnosis>		
Carer/Parent/Guardian name:	<Carer/Parent/Guardian name:>	Ph: <Carer/Parent/Guardian Phone (if different from patient)>	
Dependants/Children:	<Dependants/Children:>		
Name:	<Dependants/Children 1 Name:>	DOB/age: <Dependants/Children 1 -  Age/DOB>	
Name:	<Dependants/Children 2 Name:>	DOB/age: <Dependants/Children 2 -  Age/DOB>	
Consumer Details

This referral has been discussed with the person. They have given consent for the referral and are aware that Mental Health Services may contact them directly: <This referral has been discussed with the person. They have given consent for the referral and are aware that Mental Health Services may contact them directly>

General Practitioner Details 
Name: <DrName>	Ph: <UsrPhone>                Fax: <UsrFax>	
Practice Name: <Practice>	
Address: <UsrAddress>	

Referrer Details 
Name: <Referrer Name (If non-referring GP)> 			Organisation: <Referrer Organisation (If non-referring GP)>	

Ph: <Referrer Ph (If non-referring GP)>	Fax: 		
Date of referral: <TodaysDate>		

Risk Assessment: Select response from drop down menu. See back of form for Risk Assessment Guide and referral process. 
Identified risk areas will have a note to contact the Mental Health Triage on 13 14 65.

Risk of harm to self/others/both 	<Risk of harm to self/others/both>					

Level of problem with functioning	<Level of problem with functioning>					

Level of support available	<Level of support available>

History of response to treatment	<History of response to treatment>					

Attitude and engagement to treatment	<Attitude and engagement to treatment>					

Overall assessment of risk	<Overall assessment of risk>				

Clinical Information/Reason for Referral: <Clinical Information / Reason for Referral>

Firearms Notification: <Firearms Notification:> 	Child Protection Notification: <Child Protection Notification>

Please attach a health summary, mental health care plan if appropriate and any other relevant documentation. <Please attach a health summary, mental health care plan if appropriate and any other relevant documentation.>

Any other Providers involved in care: <Any other Providers involved in care?>

Name:  <Name> 		Discipline: <Discipline>
Ph: <Ph>

Name: <Name> 	                Discipline:  <Discipline>
Ph: <Ph>

Contact Numbers
For urgent referrals call Mental Health Triage on 13 14 65.

For non-urgent referrals fax this form to the local metropolitan Community Mental Health (CMH) team according to the consumer’s residential address. For information regarding metropolitan Mental Health catchment areas refer to www.sahealth.sa.gov.au/mentalhealthgpsharedcare

Service	Phone	Fax	Service	Phone	Fax	
Northern CMH             	7485 4300	7485 4401	Outer South CMH	8384 9599	8384 1629	
North East CMH	7425 6300	7425 6333	N Older Persons	7425 6300	7425 6345	
Western CMH	7425 3800	7425 3888	W Older Persons	8426 0600	8426 0699	
Eastern CMH	7425 5555	7425 5556	E Older Persons	7425 6400	7425 6401	
Inner South CMH	7425 8500	7425 8608	S Older Persons	7117 5037	7117 5081	
For all Child Adolescent Mental Health Service (CAMHS) referrals contact CAMHS Connect by calling 1300 222 647	8429 6184	

Risk Assessment Guide
Risk of harm to self/others	
0. None (no thoughts or action of harm).

	1. Low (Fleeting thoughts of harming themselves or harming others but no plans/current low alcohol or drug use).	2. Moderate (current thoughts/distress/past actions without intent or plans/moderate alcohol or drug use).

	3. Significant (current thoughts/past impulsive actions/recent impulsivity/some plans, but not well developed/increased alcohol or drug use).	4. Extreme (Current thoughts with expressed intentions/past history/plans/ unstable mental illness/ high alcohol or drug use, intoxicated/violent to self/others/ means at hand for harm to self/others).	
Level of problem with functioning	
0. None/Mild (No more than everyday problems/slight impairment when distressed).
	1. Moderate (Moderate difficulty in social/occupational or school functioning/reduced ability to cope unassisted).
	2. Significant Impairment in one area (either social, occupational or school functioning).	3. Serious Impairment in several areas (Social, occupational or school functioning).	4. Extreme Impairment (inability to function in almost all areas).	

Level of support available	
0. No problems/Highly Supportive (all aspects/most aspects highly supportive/self/
family/professional/ effective involvement). 	1. Moderately Supportive (Variety of support available, able to help in times of need).	2. Limited Support (few sources of help, support system has incomplete ability to participate in treatment). 	3. Minimal (few sources of support and not motivated)	4. No support in all areas. 	

History of response to treatment	
0. No Problem/ Minimal Difficulties (Most forms of treatment have been successful/ new client). 	1. Moderate Response (Some responses in the medium term to highly structured interventions). 	2. Poor Response (Responds only in the short term with highly structured interventions). 	3. Minimal Response (Minimal response even in highly structured interventions). 	4. No Response (No response to any treatment in the past). 	

Attitude and engagement to treatment	
0. No Problem/ Very Constructive (Accepts illness and agrees with treatment/new 
client)	1. Moderate Response (Variable/ ambivalent response to treatment). 	2. Poor Engagement (Rarely accepts diagnosis). 	3. Minimal Response (Client never cooperates willingly). 	4. No Response (Client has only been able to be treated in an involuntary capacity).