Patient Details	
Surname: <PtSurname>	DOB: <PtDoB>	
First name: <PtFirstName>	
Address: <PtStreet>, <PtCity>, <PtPostcode>	
Email address: <PtEmail>	
Mobile: <PtPhoneMob>   Work: <PtPhoneWk>   Home: <PtPhoneH>	
Do you give permission to receive SMS notifications or voicemail on the above numbers?	
Medicare number: <PtMCNo>   Exp: <PtMCExpiry>	Private Health Insurance number: <PtInsNo>	
Healthcare card number: <PtPensionNo>   Exp: 		
Third Party Information:  ie, WCC or MAIB 		
Cultural Background	
Does the person identify as Aboriginal/ Torres Strait/ Both: <PtEthnicity>	
Preferred Language if other than English: <Preferred language if other than english>	Country of Birth: <Country of birth>	
Interpreter Required: <Interpreter required?>	
Next of Kin details	
Name: <NOKName>	Relationship: <NOKRelation>	
Phone: <NOKContact>	
Emergency contacts details (if different from above): <Emergency contact name>	Phone: <Emergency contact phone>	

Goal of engagement	

	

	

	
 Admission	
	
 Outpatient	
	
 Day Programs	

	

	

	
Reason for referral/ patients’ current situation	
<Reason for referral/patients' current situation>	
Diagnosis	
<Diagnosis>	

If the patient is a current inpatient, please attach the admission note, recent nursing notes, any relevant legal orders for example Guardianship paperwork.

Psychiatric History	
<Psychiatric History>	

Please attach any recent pathology results.

Medications and Allergies – if applicable attach drug chart or medication summary	
Medications
<SelectedRx>
Allergies/Adverse Reactions
<Reactions>	

RISK ASSESSMENT	
	LOW	MODERATE	HIGH	EXTREME	IF PRESENT, PLEASE ELABORATE	
Suicidality/Homicidally Thoughts/Plan/Intention						
Deliberate Self Harm						
Aggression - Physical &/or verbal (including threats)						
Drug & Alcohol abuse						
Cognitive impairment						
Medical conditions						
Other						

Referrer Details: (General Practitioner)	
Name: <DrName>	Provider Number: <DrProviderNo>	
Service: <Practice>	
Phone: <UsrPhone>	Fax: <UsrFax>	
Signature:	Date: <TodaysDate>