Non-Urgent Mental Health Service Referral Form
      For response time greater than 24 hrs		
  	Consumer Details	
Last name: Patient Demographics.Surname	Given name: Patient Demographics.First Name	URN:	
DOB: Patient Demographics.DOB	Male/Female/Other: Patient Demographics.Gender	Indigenous Australian: Indigenous Australia	
Language spoken: Language spoken	Interpreter required: Interpreter required		
Address: 	Patient Demographics.Address	Ph: Patient Demographics.Phone (Mobile)	
Diagnosis:	Diagnosis		
Carer/Parent/Guardian name:	Carer/Parent/Guardia	Ph: Phone	
Dependant's/Children:	Dependant's/Children		
Name:	Name	DOB/age: DOB/AGE	
Name:	Name	DOB/age: DOB/Age	

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 be

General Practitioner Details 
Name: Treating Doctor.Name	Ph: Practice.Phone     Fax: Practice.Fax 	
Practice Name: Practice.Name	
Address: Practice.Address	

Referrer Details 
Name: Referrer Name  			Organisation: Referrer Organisatio	
Ph: Referrer Phone	Fax: Referrer Fax		
Date of referral: Miscellaneous.Date		

Risk Assessment: Select the  relevant box for each domain. See back of form for Risk Assessment Guide and referral process. 
If you identify any risk areas, contact Mental Health Triage on 13 14 65. 

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

Level of problem with functioning	Level of problem wit	

Level of support available	Level of support ava	

History of response to treatment	History of response 	

Attitude and engagement to treatment	Attitude and engagem	

Overall assessment of risk	Overall assessment o

                  Clinical Information/Reason for Referral: Clinical Information

                 Firearms Notification:  Firearms Notificati	Child Protection Notification: Child Protection Not 

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

               Any other Providers involved in care:  Any other Provider

             	 Name: Other provider 		Discipline: Other provider		Ph: Other provider Phone

            	 Name:				Discipline: 				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).