The Mental Health Nurse Program (MHNP) delivers clinical care coordination and treatment services for people with severe mental illness and complex health issues being managed in primary care settings.
The mental health nurses (MHNs):
•	provide specialised support to GPs and psychiatrists by consulting and collaborating with them on the patient's clinically related needs and goals identified in the Mental Health Treatment Plan.
•	coordinate access to and liaise with other health providers and community support agencies.
•	provide active follow-up and reviews of the patient's mental and physical health, delivering psycho-education, administering, monitoring and ensuring compliance with medications and liasing with family and carers as appropriate.

HIGH RISK MANAGEMENT
The Mental Health Program - North is not a crisis service and if your patient requires immediate care then please refer to the Mental Health Helpline 1800 332 388 or present to the Launceston General Hospital Emergency Department.	
	
Date:   <FormattedDate>	
	
Patient Details	

Surname:   <<Patient Demographics:Surname>>	First Name:   <<Patient Demographics:First Name>>	DOB:   <<Patient Demographics:DOB>>	
Address:  <<Patient Demographics:Address Line 1>>	
Suburb:  <<Patient Demographics:City>>	Postcode:   <<Patient Demographics:Postcode>>	
Contact Numbers (M):   <<Patient Demographics:Phone (Mobile)>>	(H):  <<Patient Demographics:Phone (Home)>>	Gender:  <<Patient Demographics:Gender>> 	

Referring Practitioner 	

Name:   <<Doctor:Name>>	Provider Number:   <<Doctor:Provider Number>>	
Address:    <<Doctor:Address Line 1>>, <<Doctor:City>>, <<Doctor:Postcode>>	
Telephone:   <<Doctor:Phone>>	

Eligibility Criteria	

To be eligible for the MHNP the patient must be aged 18 years or over and meet the following criteria:
•	A diagnosed mental health disorder which is severe and either episodic or persistent in nature.
•	Previous hospitalisation for treatment of a mental health disorder, or are at risk of hospitalisation.
•	Need for long term management of a mental health disorder.
•	Consent required for services from a mental healht nurse.
•	The primary care based GP or psychiatrist maintains responsibility for the patient's management.
•	The mental health disorder significantly impacts the person's social, personal and/or occupational function.

Exclusion Criteria:
Patients who are currently under the care of Adult Community Mental Health Services (ACMHS)

Clinical Information  (Please mark all that apply with an "X")	

	

Depression	

	
Obsessive Compulsive Disorder	

	
Bipolar Disorder	

	
PTSD	

	
Psychosis / Schizophrenia	

	
Grief Reaction	

	
Generalised Anxiety	

	
Personality Disorder	

	
Panic Disorder	

	
Other	

	
Phobic Disorder	

	

Additional information that will assist nurses to support the patient	

Has the person received mental health care before?
Hospital Admissions:	

	
Private	

	

Public	

	

Other	

CURRENT MEDICATIONS:
<<Clinical Details:Medication List>>	

Does the person live on his/her own?	

	
Yes	

	
No	

Is there a current carer?	

	
Yes	

	
No	

Are there children at home?	

	
Yes	

	
No	

Is an interpreter required?	

	
Yes	

	
No	

Is the patient Aboriginal or Torres Strait Islander?	

	
Yes	

	
No	

Current presenting risk:
Suicide:	

	
Low	

	
Medium	

	
Past	

Self harm:	

	
Low	

	
Medium	

	
Past	

Neglect:	

	
Low	

	
Medium	

	
Past	

Aggression:	

	
Low	

	
Medium	

	
Past	

Homicide:	

	
Low	

	
Medium	

	
Past	

For HIGH risk see Crisis Mangement on Page 2 of this referral	

Reason for referral:

	
Assessment	

	
Referral coordination to alternative services	

	
Family Support	

	
Medication monitoring and medication education	

	
Psychological Support	

	
Other	

Comments:	

	

	

	

As the patient's General Practitioner/Psychiatrist I am principally responsible for the patient's clinical mental health care:

Practitioner signature: 				Date:   <<Miscellaneous:Date>>	

______________________________________________________________________________________

PATIENT CONSENT:

I give consent for my medical information to be collected, used and disclosed between my medical referrer and the treating team at the Mental Health Nurse Program-North.

I give consent for the Mental Health Nurse Program to enter necessary information into Prospect Medical Centre’s database.

Patient signature: 				Date:   		

I give consent for the Mental Health Nurse Program to enter necessary information into Primary Health Tasmania’s  database.

Patient signature: 				Date:   		

______________________________________________________________________________________

PLEASE ATTACH A COPY OF THE PATIENT'S CURRENT GP MENTAL HEALTH CARE PLAN (MHCP) WITH THIS REFERRAL FORM SIGNED BY YOUR PATIENT

Does you practice use Healthlink?		Yes		No	
Healthlink EDI:  	

Please fax Referral and MHCP to 6344 8542