HealthWISE Social and Emotional Mental Health Support for Aboriginal and Torres Strait Islander People Referral Form

This service is supported by the Australian Government Department of Health via the Darling Downs and West Moreton Primary Health Network to provide targeted psychological therapy for Aboriginal and Torres Strait Islander people who are experiencing mild to moderate mental disorder. Clients referred under this program are those who would benefit from short-term interventions. HealthWISE funded Indigenous mental health services are targeted to Aboriginal and Torres Strait Islander people requiring primary mental health care who are unable to access Medicare subsidised mental health services. 
HealthWISE referrals from GPs for this service should include a GP Mental Health Treatment Plan. 
HealthWISE provides this service in the local government areas of Ipswich, Scenic Rim, Somerset, Lockyer Valley and Cherbourg. Services may be telephone, Skype or face to face depending on client location.
Please contact us for further information on referrals (see below for contact details)
CLIENT DETAILS
Name: <PtFullName>			DOB:	<PtDoB>	Gender: <PtSex>
Address: <PtStreet> <PtCity> <PtPostcode>	Phone:  <PtPhoneH>
Mobile:  <PtPhoneMob>		Email:  <PtEmail>
REFERRING GP:  <DrName>				Date: <TodaysDate>
Address:  <DrStreet>	 <DrCity> <DrPostcode>		Phone:  <DrPhone>
Fax Number:	<DrFax> 		Provider Number: <DrProviderNo>
<Client consent to referral>Client has consented to this referral	 <Client consent to SMS>Client has consented to be contacted via text/email 
Reason for referral: <Reason for Referral>

Has the client accessed a Mental Health Care Program previously?  <Client accessed MH services previously?>	Year:   <in what year?>

PLEASE NOTE THAT HEALTHWISE IS NOT A CRISIS SERVICE
CLIENTS WHO ARE ASSESSED AS HIGH RISK SHOULD BE REFERRED TO YOUR LOCAL HOSPITAL ACUTE CARE TEAM
FAX Referral to HealthWISE Coordinated Referral Network: 1300 452 059 Or via Medical Objects: HEALTHWISE, MENTAL HEALTH
For more information please contact HealthWISE:
Toll Free: 1800 931 540 • Email: mentalhealth@healthwise.org.au
Website: www.healthwise.org.au