Complete all required information on this referral form. This will enable us to more quickly assess the care needs and priority of the referral. Please indicate selections by placing an ‘X’ in the relevant tick box. 
ALL mandatory fields are green. 	
Consumer Details	
Referral date: <<Miscellaneous:Date>>	Consent for referral obtained: 	
Family name: <<Patient Demographics:Surname>>	
Given name(s): <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>	
Date of birth: <<Patient Demographics:DOB>>	Pronouns: 	
Preferred contact details – phone number: (m) <<Patient Demographics:Phone (Mobile)>>   (h)  <<Patient Demographics:Phone (Home)>>	
Email: <<Patient Demographics:E-mail>>	
Ethnicity: <<Patient Demographics:Ethnicity>>	Liaison Officer present: 		
Interpreter/support service required:  	If yes, language:  	
If patient identifies as Aboriginal or Torres Strait Islander Aboriginal Health Liaison Officer present: 	
Emergency contact: <<Emergency contact>>	
Relationship to patient: <<Relationship to patient>>	Consent to contact if required: <<Consent to contact if required>>	
Phone number: <<Phone number>>	Other phone contact: 	
General Practitioner name: <<Doctor:Name>>	
Practice name: <<Practice/Location:Name>>	
Phone number: <<Practice/Location:Phone>>	
Reason for Referral 	 	

Service location:	
	
TEDS North-West	
	
TEDS North	
	
TEDS South	

	

Service requested:	
	
Community Based Intensive Treatment (CBIT	
	
Diagnostic clarification	

	

	

	
Secondary consult (clinician to clinician – no pt)	
	
Inpatient admission	

	

	

	
Other (specify) 	

	

Diagnosis:	
	
Anorexia nervosa	
	
Bulimia nervosa	
	
Binge eating disorder	

	

	

	
	
Avoidant restrictive food intake disorder	
	
Other specified feeding or eating disorder	

	

	
	
Requires clarification/unknown	

	
Reason for referral: (please specify below)

Goals of referral/treatment: (please specify below)

Medical Assessment	

	

I acknowledge and have reviewed the Tasmanian Health Pathways Eating Disorder Pathway for Adults, and I am aware of the indicators for psychiatric or medical admission, and this person does not require hospital admission	

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

Blood results less than 2 weeks old, (FBE, UEC, LFT, CMP) are attached on the last page (required) 	

	
Medications:
<<Clinical Details:Medication List>>	

Anthropometry:	
Weight:     kilograms (kg)	
Date measured: 	

Height:     centimetres	
BMI (kg/m2):	

	
Weight history (include timeframe, for example 10kg loss in 2 months): (please specify below)

Observations:	
Blood Pressure – completed 2 minutes apart (both required)	

Lying:	
Standing:	

	

Heart Rate – completed 2 minutes apart (both required)	

Lying:	
Standing:	

	

Respiratory rate:	
Temperature:	

	

Amenorrhoea:	
	
Yes	
	
No	
	
N/A	

	

Physical complications:	
	
Fainting	
	
Dizziness	
	
Chest pain	
	
Dehydration	

	

	

	

	
	
Other (specify): 	

	
Nutritional intake (for example number of meals, food quantity, daily eating pattern, supplements):

Mental Health and Eating Disorder Behaviour Assessment	

Past psychiatric history:	
	
Yes	
	
No	

	

	

Detail if yes: 	

	

Drug and alcohol use disorder:	
	
Yes	
	
No	

	

	

Detail if yes: 	

	
Mental health assessment:

	
Suicidal thoughts/intent/plan	
	
Self-harm	
	
Binge eating disorder	

	

	

Does this patient have a suicide safety plan?	
	
Yes	
	
No	

	

If yes, attach or provide details:	

	

Eating disorder behaviours:	
	
Fainting	

Dizziness	
	
Chest pain	
	
Dehydration	

	

	

	

	

Other (specify):	

	
Details (for example frequency): 
	
Psychosocial History and Current Circumstances	
<<Clinical Details:Family History>>
<<Clinical Details:Social History>>

Current/Previous Community Supports	

Previous eating disorder treatment:	
	
Yes	
	
No	

	

Does this patient have an eating disorder plan	
	
Yes	
	
No	

	

If yes, attach or provide details:	

	

Psychiatrist:	
	
Current	
	
Previous	

	

Details:	

	

Psychologist:	
	
Current	
	
Previous	

	

Details:	

	

Dietitian:	
	
Current	
	
Previous	

	

Details:	

	
Risk Factors	

Current suicidal thoughts/expressed intent	
	
Work at risk	
	
Harm to others	

	

	

	
Patient has plans/means to attempt suicide	
	
Alcohol and drug use	
	
Driving risk	

	

	

	
Care of children	
	
Other (specify):	

	

	

	
Additional Information	
	
Referrer Details	
Referred from:  <<Practice/Location:Name>>, <<Practice/Location:Name>>	
Referrer: <<Doctor:Name>>	Provider Number: <<Doctor:Provider Number>>	
Phone number: <<Practice/Location:Phone>>	
Signature:	Date: <<Miscellaneous:Date>>	
Send referral to Access Mental Health by email, and for more information phone:
South:	Email: acstriagesouth@ths.tas.gov.au	Phone: 1800 332 388	Fax: 03 6173 0306
North:	Email: acstriagenorth@ths.tas.gov.au	Phone: 1800 332 388	Fax: 03 6173 0859
North West:	Email: acstriagenorthwest@ths.tas.gov.au	Phone: 1800 332 388	Fax: 03 6464 1963
NOTE: This form should be utilised to make a referral to community based public mental health services statewide for all individuals 18 years or older. If this referral is for children under 18 years –contact Child and Adolescent Mental Health Service (CYMHS) at (03) 6166 0588 to request a CYMHS Referral form.
Email or fax the completed form to Access Mental Health (available all hours) with all relevant reports.
Send to the relevant region if possible. Clear writing and current contact details are appreciated to avoid any delay in progressing this referral. Use the pdf version and a typed form would be appreciated.
Any confidential or urgent issues can be notified by telephone 1800 332 388.	
Referral RESPONSE Priority (For office use only)	
Priority	Priority meaning	Priority response	
1	EMERGENCY	Refer to emergency services	
2	URGENT	Commence within 2 hours	
3	HIGH PRIORITY	Commence within 24 hours	
4	LOWER PRIORITY	Commence within 48 hours	
5	NON URGENT REFERRAL	Refer to MH team within 2 weeks	
6	REFERRAL OUT/AWAIT CONTACT	Refer to appropriate organisation	
7	INFORMATION ATTAINED	No further action needed	
Allocated region:	 South	 North	 North-West	
Allocated Care Coordinator:	
Abbreviation key: BMI body mass index | CMP calcium, magnesium and phosphate | FBE full blood examination |
kg/m2 kilograms per metre squared | LFT liver function test | N/A not applicable | THS Tasmanian Health Service |
UEC urea, electrolytes and creatinine | CBIT Community Based Intensive Treatment | TEDS Tasmanian Eating Disorder Service |
CYMHS Child and Youth Mental Health Services	

 <<Summary:Investigation Results (Selected)>>