Mental Health Navigation Referral

Western Queensland

Or call 1800 595 212 between 8am and 6pm Mon to Fri (excluding public holidays)

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. People in crisis should be referred to the local Acute Care Team or dial 000 in an emergency.

Anyone 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).

If receiving a call from Medicare Mental Health would place the person at risk (e.g., those experiencing DFV), consider asking them 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/).

HEALTH PATHWAYS
HealthPathways offers clinicians locally agreed information to make the right decisions together with patients, at the point of care.

For more information on HealthPathways in Western Queensland, please click here.

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 phone 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/

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 *

Does a parent/guardian need to be contacted? *

YesNo

Parent/Guardian Name

Relationship to client

Contact number

Consent to be contacted via *

PhoneSMSVoicemailEmail

For domestic violence situations, please consider client's safety

CLINICAL INFORMATION

Reason for referral *

RISK ASSESSMENT

Current suicidal thoughts? *

YesNo

Current suicidal plans? *

YesNo

Current suicidal intent? *

YesNo

Current self-harm behaviours? *

YesNo

Safety plan completed? *

YesNo

Additional details (Risk assessment)

Supporting documents/files

Browse

Save and Complete Later

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

RHealth Privacy Policy