Mental Health Nurse Incentive Program Referral Form
Please contact 1800 223 365 to obtain referral code

Referral form and mental health treatment plan
to be sent directly to the Mental Health Nurse.
Referral Date	Patient Initials	Year of Birth	M/F/Other	Patient Post Code	
<<Miscellaneous:Date>>	<<Patient Demographics:Full Name>>	<<Patient Demographics:DOB>>	<<Patient Demographics:Gender>>	<<Patient Demographics:Address Postal Postcode>>	
MHNIP Referral Details:
Referral Code	Nurse Name	Phone	Fax / Email	
	<<Addressee:Name>>	<<Addressee:Phone>>	<<Addressee:Fax>>
<<Addressee:E-mail>>	
Eligibility Criteria (The patient must meet all of the criteria to eligible for MHNIP
Criteria 1*  £
The patient has been diagnosed with an eligible metnal health disorder:
List diagnosis:

Criteria 2*  £
The disorder causes significant diablement to the patients social personal and occupational functioning	
Criteria 3*   £
The patient is expected to require continuing treatment and management of their mental health disorder over the next two years	
Criteria 4*  £
The patient has experienced at least one episode of hospitalization for treatment of mental health disorder, or is at risk of requiring hospitalisation in the future if appropriate treamtent and care is not provided.	

Additional Information to support patients:
Does the patient speak a language other than English?  <<Patient Demographics:Language Spoken>>	
Does the patient live alone?	
Has the patient received specialist mental health care before ? Public    Private     Medical    Allied Health	
Is the patient receiving medication?  Benzodiasepines    Anti-depressants    Antipsychotics     Mood stabilisers	
Is there a history of aggression (physical or verbal) towards health professionals ? (for safety assessment purposed. Will not affect acceptance of referral)	
Reason for Referral 
	
Patient Consent:
By consenting to this referral, i understand that all information in this referral, and any previous referrals (where applicable) including my personal information, will be collected for the primary purpose of delivering care; and for the ongoing monitoring, reporting, evaluation and improvement of services. I consent with the understanding that this information will only be used, disclosed and stored for its primary purpose, between my health service provider(s), the Department of Health, and the Nepean Blue Mountains Primary Health Network (NBMPHN) and affiliated partner organisations(s)* in accordance with the Australian Government Privacy Act, 1988.
*Affiliated partner organisation(s) means those required to support the monitoring, reporting, evaluation and/or clinical governance for this service.
Patient Signature:  
Date:  <<Miscellaneous:Date>>	GP Signature:
(Provide GP details or stamp)