Date of referral: <<Miscellaneous:Date>>
PATIENT DETAILS	
Title: <<Patient Demographics:Title>>	Full name: <<Patient Demographics:Full Name>>	
Date of Birth: <<Patient Demographics:DOB>>	Age: <<Patient Demographics:Age>>	Gender: <<Patient Demographics:Gender>>	
Address: 	<<Patient Demographics:Full Address>>	
Mobile No.: <<Patient Demographics:Phone (Mobile)>>	Home phone No.: <<Patient Demographics:Phone (Home)>>	
Email address: <<Patient Demographics:E-mail>>	
	
REFERRER DETAILS	
Full Name: <<Doctor:Name>>	
Practice Name: <<Practice:Name>>	
Address: 	<<Practice:Address>>	
Phone: <<Practice:Phone>>	Fax: <<Practice:Fax>>	
Email address: <<Practice:E-mail>>	
	
REASON FOR REFERRAL (eligibility criteria)	
GP Treatment plan attached?	¨	Yes	¨	No	Date of plan:	
¨	A diagnosed mental health disorder (according to criteria defined in the Diagnostic and Statistical Manual of Mental health Disorders – IV Ed of the World Health 
Organisation/ Diagnostic and Management Guidelines for Mental Health Disorders in Primary Care: ICD-10 Chapter V Primary Care version)	¨	
The patient is expected to need long term management of the mental health disorder	

¨	
The patient provides consent to services from a mental health nurse	

¨	
A primary care based GP or psychiatrist maintains responsibility for the patient’s management	

¨	The patient has been previously hospitalised for treatment for the mental health disorder, or are at risk of hospitalisation	¨	The mental health disorder significantly impacts the person’s social, personal and/or occupational function	
Has the patient previously accessed the Mental Health Nurse Initiative Program?  Y/N	
MDS Client Key (if known):	
	
DIAGNOSIS	
Diagnosed by:	
Address:		
Phone: 	Fax: 	
Email address:	
Further details:		

RISK FACTORS	
¨	Recent suicide attempt	¨	Homelessness / unstable accommodation	
¨	Harm to others	¨	Risk of exploitation	
¨	Substance Abuse	¨	Care of children	
¨	Poor self-care			
Further details:		
Risk assessment completed	¨	Yes	¨	No	Date:	
	
MENTAL HEALTH ISSUES	
¨	Sleep	¨	Hallucinations	
¨	Appetite / food intake	¨	Delusions	
¨	Depressed mood	¨	Other			
¨	Elevated mood			
Further details:		
Current Medication:	<<Clinical Details:Medication List>>	
	
¨	As the referring medical practitioner I confirm:	
	I am satisfied that the patient understands that by referring them to the MHNP their personal information will be provided to the MHNP provider, that the provider will make contact with them directly and that they have provided informed consent for this referral.	
Signed:	Date:	

Please send referrals to:
Richmond Fellowship Tasmania
F: 03 6228 3300
E: referrals @rftas.org.au