Western Queensland

Medicare Mental Health

(Formerly Head to Health)

Mental Health Navigation

Referral Form

Or call 1800 595 212 between 8:30am and 5:00pm Mon to Fri

If you are outside of Western Queensland, please call 1800 595 212 instead of using this form.

IMPORTANT

I understand that Medicare Mental Health (formerly Head to Health) is NOT a crisis service. Patients in crisis should be referred to the local Acute Care Team or dial 000 in an emergency.

Our operating hours are Monday to Friday 8.00am-6.00pm (excluding public holidays).

Patients can self-refer by calling Medicare Mental Health directly on 1800 595 212 and will be assessed, where appropriate, using the Initial Assessment and Referral Decision Support Tool (IAR-DST).

For patients at risk of accepting a random call from Medicare Mental Health (e.g., those experiencing DFV), consider asking the client to call us directly.

For diagnostic and management advice, call the GP Psychiatry Support Line on 1800 161 718 (or visit https://www.gpsupport.org.au/).

CONSENT

Consent has been given by patient before the submission of this e-referral form.

If under 18, the referral outcome can be discussed with guardian.

The patient (or their guardian or representative) has consented to the collection and disclosure of their personal and health information to the Medicare Mental Health Service. They have acknowledged and understand that:

Medicare Mental Health may contact them to discuss their referral

The phone call will come from 07 4599 3595.

Their personal information will be managed in accordance with the relevant privacy policy and statements, which can be found here: https://www.rhealth.com.au/ (see link at bottom of page).

I acknowledge that I have read and provide consent *

Referrer details

Referral origin *

Referral date *

Referrer name *First name and last name

Referrer profession *

Organisation *

Other organisation *

Street address *

City *

State *

Postcode *

Referrer email *

Referrer phone *

GP details

Recording these details is optional, if the client is happy for their GP details to be provided.

Are you this persons regular GP? *

YesNo

GP name

GP clinic

GP phone number

Does client have a MHTP? *

YesNoUnknown

If you are unsure, please select 'Unknown'

Client details

First name *

Last name *

Date of birth *If you are unsure, enter an estimate.

Gender *

PronounEnter the client's preferred pronouns

Aboriginal and/or Torres Strait Islander Origin *

Country of birth *

Main language spoken at home *

Other language *

Mobile *

Phone

Email Address

Street address

City *

State *

Postcode *

Clinical information

Reason for referral *

Risk assessment

Current suicidal thoughts? *

YesNo

Current suicidal plans? *

YesNo

Current suicidal intent? *

YesNo

Current self-harm behaviours? *

YesNo

Additional details (Risk assessment)

Supporting documents/files

Browse

Save and Complete Later

For general enquiries to the Medicare Mental Health team, please email mmh@rhealth.com.au or call 1800 595 212.