RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>			
			
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 data?>>	

Patient Details
First Name:	<<Patient Demographics:First Name>>	
Last Name:	<<Patient Demographics:Surname>>	
Date of Birth:	<<Patient Demographics:DOB>>	
Is date of birth Accurate:	<<Is date of birth accurate? >>	
Gender:	<<Patient Demographics:Gender>>	
Mobile:	<<Patient Demographics:Phone (Mobile)>>	
Phone:	<<Patient Demographics:Phone (Home)>>	
Address:	<<Patient Demographics:Address Line 1>>	
City:	<<Patient Demographics:City>>	
Postcode:	<<Patient Demographics:Postcode>>	
State:	<<Patient Demographics:State>>	
Ethnicity:	<<Patient Demographics:Ethnicity>>	
Aboriginal and/or Torres Strait Islander:	<<Patient Demographics:ATSI>>	
Main Language Spoken:	<<Patient Demographics:Language Spoken>>	
English Skill:	<<English Skill>>	
Is an interpreter required:	<<Patient Demographics:Requires Interpreter>>	

Referral Details
Referrer Name:	<<Doctor:Name>>	
Referrer Email:	<<Practice/Location:E-mail>>	
Referring Practice:	<<Practice/Location:Name>>	
Service Type:	<<Service type>>	
Service Provider:	<<Provider>>	

Medicare Mental Health Phone Service	
Servicing people in the Darling Downs and West Moreton PHN catchment area. Medicare Mental Health Phone Service provides a free, confidential referral 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 64 22 55.	
Additional service details are available at www.medicarementalhealth.gov.au.

Reason for Referral
<<Reason for referral?>>	

Diagnosis
<<Diagnosis>>	

Additional Referral Details
Has a GP Mental Health Treatment Plan been completed?:	<<GP Mental Health Treatment Plan Completed?>>	
Active Suicide Referral Flag:	<<Is there an active suicide risk for this client?>>	

Additional comments regarding this referral
<<Additional comments>>	

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 8
Do not remove site code	

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