Primary Mental Health Services - Referral

Patient Information

Gender
Main Language Spoken at Home
Aboriginal or Torres Strait Islander
Homelessness
Employment Type

(For child/youth referrals please complete with parents status)

Spoken English Level
Marital Status
Labour Force Status

(For child/youth referrals please complete with parents status)

Source of income

(For child/youth referrals please complete with parents status)

Mental Health Presentations

Presenting Issues
Severity
Outcome Tool Score
Previous Mental Health History or Treatment
Principal Diagnosis
Psychotropic Medication

Priority Group

Suicide Prevention Referral

Is this person currently at high risk of suicide?
Type
Vulnerable Group

Treatments

Referred for which strategies

Additional Information

Referrer & Consent

Referrer Details

Consent - Patient or Parent/Guardian for a child

(Cross out any statement that does not apply)
Please ensure the following is complete before sending to WentWest

WSPIR Client Information & Referral Form

This form needs to be completed in addition to the PMHC Referral Form

Please complete ALL areas and attach available reports or assessments

Program Inclusion Criteria - All Inclusion Criteria must be met.

The Partners in Recovery Program aims to better support people with a severe and persistent mental illness who also have complex needs and require substantial support. This program is for people who:

  1. Have a severe and persistent mental illness and complex needs
  2. Are 18 to 64 years of age
  3. Are not receiving, but require multiple services and support
  4. Need substantial assistance to engage with service
  5. Australian Citizen or permanent Australian Resident
1. Does the client currently have a NDIS package?
2. Is the client willing to collect the evidence required for their NDIS application?

The following SIX areas must be met (one “Yes” in each of sections 3 to 8)

3. Identifies “severity”
4. Identifies “persistence”
5. Has complex needs that require services from multiple agencies
6. Requires substantial support/assistance to engage with services to meet their needs
7. No existing coordination arrangements in place, or arrangements have failed/contributed to issues and may be addressed by WSPIR
8. The person or their guardian is willing to participate in the PIR initiative

Referrer

Or

Secondary Contact Details

Additional Information

Is there any risks we should be aware of when working with this person, current or historical?
Does the client have a nominated carer or guardian?
Is the client at risk of harm to themselves or others?

Mental & Physical Health

Does the client have a diagnosis of a severe & persistent Mental Illness
Does the client have a history of hospitalisations due to Mental Illness?
Does the client have any secondary diagnosis e.g. Intellectual Disability, Acquired Brain Injury or Physical Disability, Diabetes, High Blood Pressure, Dental, Medication Issues, etc?

Psychosocial Support Requirements

Does the client usually need support from a person or assistive equipment in the following areas? Please provide details.

1. Communication i.e. understanding & being understood by other people?
2. Social Interaction i.e. making and keeping friends & coping with feelings and emotions?
3. Learning i.e. understanding, remembering information & learning new things?
4. Mobility i.e. getting out of bed and moving around the home & outside the home?
5. Self-care i.e. taking a bath or shower, toileting, dressing & eating, caring for own health?
6. Self-management i.e. doing daily jobs, handling money, problem solving, making decisions?
7. Is the client currently receiving any support from family, friends or formal services?

Housing, Finance, Employment

1. Current Housing Situation

I. Homeless
II. FACS Housing
III. Private Residence

2. Current Employment Status

I. Employed
II. Unemployed
III. Job seeking
3. Is the Client receiving Centrelink Benefits?
I. Disability Support Pension
II. New Start Allowance
III. Other

Current Care Coordination Supports

Consider all health & community services including doctors & psychologists

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    MENTAL HEALTH AREAS

    Resources and Links

    If you require a downloadable version of PMHC Referral Form, please download the following interactive PDF.
    ACN 099 255 103
    ABN 80 099 255 106

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