Region	
Email	
Fax	

South	
acstriagesouth@ths.tas.gov.au	
03 6173 0306	

North	
acstriagenorth@ths.tas.gov.au	
03 6173 0859	

North West	
acstriagenorthwest@ths.tas.gov.au	
03 6464 1963	

PLEASE NOTE: 
This form should be utilised to make a referral to community based public mental health services state-wide for all individuals 18 years or older. If this referral is for children under 18 years – please contact Child & Adolescent Mental Health Service (CAMHS) on (03) 6166 0588 to request a CAMHS Referral form. 
Using clear writing and providing current contact details will help avoid any delay in progressing this referral. This form is printable but typing in the fillable fields is preferred and appreciated. Any confidential or urgent issues can be notified by telephone 1800 332 388.
Please email or fax the completed form to Access Mental Health (available all hours) with all relevant reports. Please send to the relevant region if possible.	

Patient Details	
Name	<<Patient Demographics:Full Name>>	DOB	<<Patient Demographics:DOB>>	
Address:	<<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>	Postcode	<<Patient Demographics:Postcode>>	
Phone	<<Patient Demographics:Phone (Home)>>	Mobile	<<Patient Demographics:Phone (Mobile)>>	
Next of Kin/ Carer	<<Patient Demographics:Next of Kin>>	NOK/ Carer phone	<<Patient Demographics:Next of Kin Phone>>	
Cultural Background	<<Patient Demographics:Ethnicity>>	Preferred Language	<<Patient Demographics:Language Preferred>>	
Indigenous or Torres Strait Islander	<<Patient Demographics:ATSI>>	Interpreter needed	<<Patient Demographics:Requires Interpreter>>	

Referrer Details	
Name	<<Doctor:Name>>	
Address	<<Doctor:Address>>	
Phone	<<Doctor:Phone>>	Fax	<<Doctor:Fax>>	
Profession	General Practitioner 	
Length of Referral	<<Length of Referral:>>	
Referral Date	<<Miscellaneous:Date>>	

Part A
1.	Is the person aware of this referral? <<Is the person aware of this referral?>>
2.	Reason for Referral to Mental Health Services (Please ‘X’ all boxes that apply)
	
Assessment and MHS to manage	
	
Assessment and co-management	

	

	
Medication advice and continued GP Management	

	

Assessment and suggestions for GP to manage	
	
Other	

	

a.	Urgency
	
Routine	
	
Urgent (Please indicate what risk factors make this referral urgent)	

b.	Presenting Problems: (please detail below)

c.	Risk Factors (Please ‘X’ all boxes that apply)
	
Current suicidal thought/expressed intent	
	
Work at Risk	

	

	
Harm to others	
	
Patient has plans/meant to attempt suicide	

	

	
Alcohol and Drug Use	
	
Driving Risk	

	

	
Care of Children	
	
Other	

Additional Information: (please detail below)

	

3.	Mental Health Review (Please ‘X’ all boxes that apply)
Sleep	
	
Early Morning Wakening	
	
Poor Sleep	
	
No Sleep	
	
Problem Duration	

	

	

	

Appetite	
	
Significant weight loss	
	
Mild loss	
	
Excessive/unhealthy weight gain	

	

	

	

Energy and 	
	
Lack of energy	
	
Loss of motivation	
	
Mild anhedonia	
	
Marked anhedonia	

Motivation	

	

	

	

	

	

Mood 	
	
Abnormally low mood	
	
Elevated mood	
	
Irritability	
	
Abnormal mood changes	

	

	

	

Delusions and 	
	
Delusional ideas	
	
Paranoia	
	
Hallucinations	
	
Command hallucinations	

hallucinations	

	

	

	

Further information

Other important factors (please detail below)

Mental Health History (please detail below)

Relevant Medical History
<<Clinical Details:History List>>	

Social History
<<Clinical Details:Social History>>	

Current Medications
<<Clinical Details:Medication List>>	

Part B – Adults Aged 65+ (please complete this section only when referring adults aged 65 years and older)

Does this person live alone?	
	
YES	
	
NO	

	

	

Is this person aware of this referral?	
	
YES	
	
NO	

	

	

Is this person caring for someone else?	
	
YES	
	
NO	

	

	

Can they travel to an appointment	
	
YES	
	
NO	

	

	

Who is the initial contact person	

	

	

Has the person been seen by ACAT or other services?	
	
YES	
	
NO	

	

	

Details of ACAT or other services	

	

	

If yes, are there any cognitive assessments (e.g., MOCA), pathology results or neuroimaging results available?	
Please attach any new assessments or investigations	

	

	

Are you aware of any enduring or appointed guardianship and/or administration orders for this patient?	

	

	

	

	

	

Does this person have their medication/s supervised?	

	

	

	

Does this person have a “Community Pharmacy Packaging”	

	

	

	

Is there a cognitive screening	

	

	

	

Recent Investigations/ General medical conditions	
Please attach