FocusOne Health Mental Health Services Referral & GP Treatment Plan

(Medicare Item 2715 / 2717)

Fax to FocusOne Health on Confidential Fax Number: 08 85825050

Patient Name: Address: Phone - BH: Phone - AH:	Date Plan Prepared:
K10 Score
DOB:	Gender:
Key Family Contact/ Support
Name: Relationship: Phone No:
FocusOne Health can leave a message requesting call back on answering machine: Yes / No
GP Name Practice Provider No
Preferred Clinician (please circle)	Male Female
Preferred Town for service	Berri Barmera Loxton Pinnaroo Waikerie Mt. Gambier Millicent Naracoorte Bordertown Keith Kingston
Can the person travel to for an appointment if required	 Yes ________________(please provide location)  No
Provisional Diagnosis: (please tick)
Anxiety Generalised Anxiety Phobia Panic Disorder Anxiety Other ______________________________________________ Depression Perinatal Depression  Anxiety & Depression Bi-Polar Psychotic disorder Adjustment disorder Sleep disorder Bereavement Other _____________________________________________________

Precipitating Factors
Any recent change in circumstances
Medications:
Past History:
Current presenting complaint:
Other Relevant Information:
Aboriginal Or Torres Strait Islander	Yes No
Has this person ever received specialist mental health care?	Yes No
Alcohol? Illicit Drugs? Smoker?	Yes  No Yes  No Yes  No	How Often? Details: How Many?
Any known Allergies?	 Yes  No Details:
Language spoken at home: How well does this person speak English: Is an interpreter required?	Not at all  A little  Well  Very Well Yes  No
Does this person live alone?	 Yes  No
Low Income Earner? Type of Pension received?	Yes  No Aged  Disability  Sickness  Unemp.  Repat.
Highest Education Level completed:	 Year 9  Year 10  Year 11  Year 12 Tertiary  Other

Mental State Examination:
Appearance & General Behaviour Normal  Other 	Mood/ Affect Normal  Other 
Thinking Normal  Other 	Speech Normal  Other 
Perception Normal  Other 	Sleep Normal  Other 
Cognition Normal  Other 	Appetite Normal  Other 
Attention/Concentration Normal  Other 	Motivation/Energy Normal  Other 
Memory Normal  Other 	Judgement Normal  Other 
Insight Normal  Other 	Anxiety Symptoms Normal  Other 
Orientation Normal  Other 	Other: Normal  Other 

Risk Assessment - This section must be completed for Referrals to be accepted by FocusOne Health.

Risk of Harm to self or others – please provide details
Current Risk	Previous History	Protective factors	Other relevant information
Suicidal thoughts
Suicidal Plan
Suicide Intent
Attempts
Risk to others

Client risk

Low – Moderate – refer to FocusOne Health/Headspace

High - if client is assessed as high risk and/or acute and/or requiring crisis/immediate or urgent intervention please refer to Community Mental Health Team and/or Hospital.

Please tick boxes below

Patient provided with Rural and Remote number 13 14 65

Patient aware of GP business hours or hospital after hours.

Client is aware to expect a call from FocusOne Health within 48 hours of receipt of referral to arrange an appointment time.

The timeframe for FocusOne Health Clinical Services is approximately 3 – 6 weeks. Unless otherwise indicated in correspondence from FocusOne Health.

It is important as the GP to monitor the patients care in the interim.

Mental Health Care Plan

Patient’s main concerns / issues	Goals	Treatments
Emergency Care/ Relapse Prevention Plan
Patient Education Given: Yes / No Copy of Plan given to Patient: Yes / No Next Review Due: / /

Patient Consent to Referral and Mental Health Treatment Plan
– must be	signed	by both GP and patient
I ____________________________ consent to this Treatment Plan to proceed and I agree to information about my mental health being recorded in my medical file and being shared between the GP and FocusOne Health Clinical Services Team to whom I am referred, to assist in the management of my health care. X____________________________________ ____________ Signature (patient) Date I Dr______________________ have discussed the proposed referral(s) with the patient and am satisfied that the patient understands the proposed uses and disclosures and has provided their informed consent to these. x____________________________ _______ __ _____________________ ______________ GP Signature GP Name Date

Fax to: FocusOne Health Confidential Fax Number: 08 8582 5050

K10

For all questions, please fill in the appropriate response circle. Fill in the circles like this: Please do not tick or cross the circles.

In the past 4 weeks:	None of the time	A little of the time	Some of the time	Most of the time	All of the time

About how often did you feel tired out for no good reason?

About how often did you feel nervous?

About how often did you feel so nervous that nothing could calm you down?

About how often did you feel hopeless?

About how often did you feel restless or fidgety?

About how often did you feel so restless you could not sit still?

About how often did you feel depressed?

About how often did you feel that everything was an effort?

About how often did you feel so sad that nothing could cheer you up?

About how often did you feel worthless?

Today’s date

Day	Month	Year

This document may be freely downloaded and distributed on condition no change is made to the content. The information in this document is not intended as a substitute for professional medical advice, diagnosis or treatment. Not to be used for commercial purposes and not to be hosted electronically outside of the Black Dog Institute website. www.blackdoginstitute.org.au

Mental Health Services Referral & GP Treatment Plan

K10	p. 2

Explanatory Notes

What is the K10 and how is it scored?

The K10 is widely recommended as a simple measure of psychological distress and as a measure of outcomes following treatment for common mental health disorders. The K10 is in the public domain and is promoted on the Clinical Research Unit for Anxiety and Depression website (www.crufad.org) as a self report measure to identify need for treatment.

The K10 uses a five value response option for each question – all of the time, most of the time, some of the time, a little of the time and none of the time which can be scored from five through to one.

The maximum score is 50 indicating severe distress, the minimum score is 10 indicating no distress.

Questions 3 and 6 are not asked if the preceding question was ‘none of the time’ in which case questions 3 and 6 would automatically receive a score of one.

For further information on the K10 please refer to www.crufad.org or Andrews, G Slade, T. Interpreting score on the Kessler Psychological Distress Scale (K10). Australia and New Zealand Journal of Public Health: 2001; 25:6: 494-497.