Patient Details	
Surname: <<Patient Demographics:Surname>>	DOB: <<Patient Demographics:DOB>>	
First name: <<Patient Demographics:First Name>>	
Address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>	
Email address: <<Patient Demographics:E-mail>>	
Mobile: <<Patient Demographics:Phone (Mobile)>>   Work: <<Patient Demographics:Phone (Work)>>   Home: <<Patient Demographics:Phone (Home)>>	
Do you give permission to receive SMS notifications or voicemail on the above numbers?	
Medicare number: <<Patient Demographics:Medicare Number>>   Exp: <<Patient Demographics:Medicare Expiry Date>>	Private Health Insurance number: <<Patient Demographics:Health Insurance>>	
Healthcare card number: <<Patient Demographics:Pension Number>>   Exp: 		
Third Party Information:  ie, WCC or MAIB 		
Cultural Background	
Does the person identify as Aboriginal/ Torres Strait/ Both: <<Patient Demographics:ATSI>>	
Preferred Language if other than English: <<Patient Demographics:Language Preferred>>	Country of Birth: <<Patient Demographics:Country of Birth>>	
Interpreter Required: <<Patient Demographics:Requires Interpreter>>	
Next of Kin details	
Name: <<Patient Demographics:Next of Kin>>	Relationship: <<Patient Demographics:Next of Kin Relationship>>	
Phone: <<Patient Demographics:Next of Kin Phone>>	
Emergency contacts details (if different from above): <<Patient Demographics:Emergency Contact>>	Phone: <<Patient Demographics: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
<<Clinical Details:Medication List>>
Allergies/Adverse Reactions
<<Clinical Details:Allergies/Adverse 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: <<Doctor:Name>>	Provider Number: <<Doctor:Provider Number>>	
Service: <<Practice/Location:Name>>	
Phone: <<Practice/Location:Phone>>	Fax: <<Practice/Location:Fax>>	
Signature:	Date: <<Miscellaneous:Date>>