Wellways to Recovery
referral form

	                                                    Version 1.4 September 2022

In collaboration with Mental Health Services Tasmania	

 PARTICIPANT DETAILS		
Family name: <PtSurname>	Given names: <PtFirstName> <PtMidName>	
Date of Birth: <PtDoB>	 Address: <PtStreet> <PtCity> <PtPostcode>	
Contact numbers:  (m) <PtPhoneMob>
                                (h) <PtPhoneH>	 Do you identify as Aboriginal or Torres Strait Islander?   <Identify as ATSI?>
 What gender do you identify as?      <Gender Identification>
 
URN:  <URN (if known)>	

 REFERRER DETAILS		
 Referral date: <TodaysDate>	 Referrer name: <UsrName>	
 Contact number: <DrPhone>	 Organisation: <Practice>	
 Address: <DrAddress>	 Email: <PracEmail>
REFERRER SIGNATURE	

 DIAGNOSIS:   <Diagnosis>	
 CLINICAL SIGNOFF:  <Clinical Signoff>	
 Email referral: tasmania@wellways.org                 <Region>	
 Has the person consented to this referral?            <Consented to Referral>	
 Has the information session occurred?      <Information session occurred?>         <Date of Session>	

	 REASON FOR REFERRAL			
<Ref - Reason - Managing mental health>	  Managing mental health	<Ref - Reason - Responsibilities>	  Responsibilities	
				
<Ref - Reason - Relationships>	  Relationships	<Ref - Reason - Social networks>	  Social networks	
				
<Ref - Reason - Physical health and self care>	  Physical health and self care	<Ref - Reason - Identity and Self Esteem>	  Identity and self esteem	
				
<Ref - Reason - Addictive behaviour>	  Addictive behaviour	<Ref - Reason - Work>	  Work	
				
<Ref - Reason - Living skills>	  Living skills	<Ref - Reason - Trust and hope>	  Trust and hope	

 PLEASE EXPLAIN THE REASONS FOR REFERRAL INDICATED ABOVE:

<Explanation for Referral Reasons>	

 HOW DOES THE DIAGNOSIS AFFECT PARTICIPANT (examples: relapse, frequency, triggers, early warning signs)

<How does diagnosis affect participant>	

 Mental Health Order:     <Mental Health Order?>	 Administration/Guardianship Order:  <Administration Guardianship Order?>	

 CURRENT LIVING ARRANGEMENTS:

<Current Living Arrangements>	

 PRESCRIBED MEDICATION:
<SelectedRx>
Other comments: 	

OTHER HEALTH ISSUES: (e.g. diabetes, cardiac conditions, allergies, alerts etc): 
<Reactions>
<SelectedPMH>	

 RISKS/SAFETY ISSUES: Please provide notes regarding all risks rated moderate or high.	
	Rating	 DETAILS/OTHER COMMENTS	
 Suicidality (thoughts,plan,intent,history)	 <Suicidiality (Details if Moderate or higher)>	 <Suicidality - Details or Comments>	
 Risk of harm to self	 <Harrm to self (provide details if mod or higher)>	 <Harm to self - Details or Comments>	
 Risk of harm to others	 <Harm to Others  (Details if Moderate or higher)>	 <Harm to others - Details or Comments>	
 Risk of harm from others	 <Harm from others (Details if Moderate or higher)>	 <Harm from others - Details or Comments>	
 Avoiding contact	 <Avoiding contact  (Details if Moderate or higher)>	 <Avoiding contact - Details or Comments>	
 Barriers relating to culture	 <Culture Barriers (Details if Moderate or higher)>	 <Culture Barriers - Details or Comments>	
 Inappropriate sexual behaviours	 <Inappt Sexual behaviour (details if mod or higher)>	 <Sexual behaviours  - Details or Comments>	
 Disability issues	 <Disability issues  (Details if Moderate or higher)>	 <Disability issues - Details or Comments>	
 Cognitive impairment	 <Conitive impairment   (details if mod or higher)>	 <Cognitive Impairment - Details or Comments>	
 Impulsive behaviours	 <Impulsive behaviours (Details if moderate or higher)>	 <Impulsive behaviours - Details or Comments>	
 Forensic history	 <Forensic history   (details if mod or higher)>	 <Forensic History - Details or Comments>	
 Other Vulnerabilities (ie financial, neglect, etc)	 <Other vulnerabilities   (details if mod or higher)>	 <Other vulnerabilities - Details or Comments>	

 COMMORBIDITY ISSUES OR MISUSE (e.g. disability, alcohol, drug, gambling, hoarding):	
 Current / recent:        <Current / recent Commorbidity or misuse>	
 Type, frequency and amount of use:   <Type, frequency and amount of use>	
 Does the client have relevant services involved:      <Does the client have relevant services involved>	
 Please Provide details:    <If yes, provide details> 	
FAMILY, SOCIAL SUPPORTS, COMMUNITY AGENCIES, OTHER AND/OR PETS INVOLVED:
<Family/social support, community agencies or pets>	

 Does the person have a Mental health Plan?        <Does the person have a Mental Health Plan>    <If yes, please attach>	
 Does the person have a Discharge Plan?                   <Does the person have a Discharge Plan>    <If yes, please attach..>	
 Other/additional comments   <Other Comments>  	
 Is the person currently with DHHS Mental Health Services?       <Person currently with DHHS MH Services>