RE: <PtFullName>
DOB: <PtDoB>			
			
Does the patient consent for their personal information to be collected and used for the provision of services?

This includes making personal information available for the purpose of intake and access to the most appropriate service.

Note - Patient must consent to provision of data for this service to proceed.	<Does the patient agree to the provision of their personal information for the purpose of service delivery? Patient must consent to provision of data for this service to proceed.>	

Patient Details
First Name:	<PtFirstName>	
Last Name:	<PtSurname>	
Date of Birth:	<PtDoB>	
Is date of birth Accurate:	<Is date of birth Accurate?>	
Gender:	<PtSex>	
Mobile:	<PtPhoneMob>	
Phone:	<PtPhoneH>	
Address:	<PtStreet>	
City:	<PtCity>	
Postcode:	<PtPostcode>	
State:	<PtState>	
Ethnicity:	<PtEthnicity>	
Main Language Spoken:	<Langauge Spoken at Home>	
English Skill:	<English Skill>	
Is an interpreter required:	<Is an interpreter required?>	

Referral Details
Referrer First Name:	<DrFirstName>	
Referrer Last Name:	<DrSurname>	
Referrer Email:	<PracEmail>	
Referring Practice:	<Practice>	
Service Type:	<Service Type>	
Service Provider:	<Provider>	

Kingaroy Medicare Mental Health Centre	
Servicing people in Kingaroy and surrounding areas. Kingaroy Medicare Mental Health Centre (formerly known as Kingaroy Head to Health) provides a free, confidential service for anyone seeking help for their wellbeing or wanting support for a patient or someone they care about. If the person has acute mental health needs, refer to MH Call on 1300 642 255.
	
Additional service details are available at the Head to Health website.

Reason for Referral
<Reason for referral?>	

Additional Referral Details
Active Suicide Referral Flag:	<Is there an active suicide risk for this client?>	

Additional comments regarding this referral
<Additional comments regarding this referral>	

While RHealth will assist in the carriage of this referral to an appropriate provider, RHealth does not take responsibility or guarantee the provision of service to this client, or the acceptance of this referral by the selected or alternate service provider.

PHN Site Code: DDWMPHN
Version 7.6
Do not remove site code	

Insert Mental Health Care Plans or additional information below this text.