The Mental Health Nurse Access Program (MHNAP) program delivers clinical care coordination and treatment services for adults with complex and severe mental health issues being managed in primary care settings. The mental health nurses (MHNs):
•	provide specialized support to GPs and psychiatrists by consulting and collaboration with then in 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 liaising with family and carers as appropriate.
MHNAP eligibility criteria
To be eligible for MHNAP the patient must be aged 18 years or over and meet all of the following criteria 
(please tick to confirm that all criteria are met):	
¨	A diagnosed mental health disorder (according to criteria defined in the Diagnostic and Statistical Manual of Mental Health Disorders - Fifth Edition of World Health Organization Diagnostic and Management Guidelines for Mental Health Disorders in Primary Care: ICD-10 Chapter V Primary Care Version) which is severe and either episodic or persistent in nature.		¨	
The patient is expected to need long term management of their 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 hospitalized for treatment for their mental health disorder, or are at risk of hospitalisation.		¨	The mental health disorder significantly impacts the person’s social, personal and/or occupational function.	
Patient Details	
Last name:		Given name/s:	
<PtSurname>		<PtFirstName> <PtMidName>	
Gender:		Date of birth:	
<PtSex>		<PtDoB>	
Residential street address:		Suburb:		Postcode:	
<PtStreet>		<PtCity>		<PtPostcode>	
Postal address (if different from residential address):		Suburb:		Postcode:	
<PtPOAddress>		<PtPOCity>		<PtPOPostcode>	
Mobile Phone:	Home Phone:	Work Phone:	
<PtPhoneMob>		<PtPhoneH>		<PtPhoneWk>	

Additional Notes

NORTH WEST 64 AREA CODE
Fax numbers & email addresses for referrals	
Location of services	Fax number	Email address	
Burnie	03 6411 4729	receptionwynyard@ruralhealthtas.com.au	
Circular Head	03 6411 4729	receptionwynyard@ruralhealthtas.com.au	
King Island	03 6411 4729	receptionwynyard@ruralhealthtas.com.au	
Waratah-Wynyard	03 6411 4729	receptionwynyard@ruralhealthtas.com.au	
West Coast	03 6411 4729	receptionwynyard@ruralhealthtas.com.au	

GP Treatment Plan is attached:	
¨ Yes (note this is a requirement)		
Reason for referral:	
	
Current medication:	
<SelectedRx>	
General practitioner / psychiatrist	
Practitioner name:		Practice name:	
<DrName>		<Practice>	
Practice phone number:		Practice fax number:	
<UsrPhone>		<UsrFax>	
					
¨	As the referring medical practitioner I confirm:
I am satisfied the patient understands that by referring them to the Mental Health Nurse Access Program (MHNAP) that their personal information will be provided to the MHNAP provider, that the provider will make contact with them directly, and they have provided informed consent for this referral.	
Signature:		Date:	
		<TodaysDate>	
Next steps	
Please fax this referral form and the GP Mental Health Treatment Plan to:	
Please refer to the MHNAP provider in the region in which the patient resides (refer to ‘Location of services’):	
•	For the North West 64 Area Code Region fax numbers and email addresses, please see above	
•	If you wish to speak to a MHNAP provider, please call 03 6452 1266