PCCS Plus Social®
referral form

Forward completed Referral via Medical Objects to: Head to Health Gold Coast Referrals
or Fax 07 3186 4099

By consenting to this referral, the person is consenting to the sharing of their personal information. The information contained in the referral is used by the Head to Health phone service to: (1) deliver assessment and referral services, (2) for monitoring, aggregate reporting and evaluation purposes to improve quality and access to care. This information will be passed on to the recommended provider who will contact the person.

Please indicate the information in this form has been discussed with, and provided to, the patient.  <Indicate this info has been discussed and provided to patient>

Patient or Parent/Guardian/Carer consents to Referral  <Patient or Parent/Guardian/Carer consents to referral>

Referrer consents to the collection and storage of referrer details on internal database  <Referrer consents to collection and storage of referrer details on internal database>

Referral Date  <TodaysDate>

REFERRER DETAILS

Referrer's role	<Referrer's role>	
Referrer's name	<DrName>	
Referrer's email	<DrEmail>	
Practice name	<Practice>	
Practice address	<UsrAddress>	
Practice phone no	<UsrPhone>	
Practice fax no	<UsrFax>	

PATIENT DETAILS	

RE:  <PtDetails>  	DOB: <PtDoB>  	
Gender  <PtSex>	Other gender identity (if applicable)  <Patient - Other Gender Identity (if applicable)>	
Address   <PtAddress>	Experiencing homelessness  <Experiencing homelessness>	
Home phone no  <PtPhoneH>  	Mobile phone no  <PtPhoneMob>	
Aboriginal &/or Torres Strait Islander Status  <Does the person identify as Aboriginal &/or TSI>	Health Care/Pension Card:  <Health Care/Pension Card>

Expiry date: <Health Care/Pension Card expiry date>	
	Culturally or Linguistically Diverse (CALD)  <Culturally or Linguistically Diverse (CALD)>
Language spoken at home  <Language spoken at home> 
Interpreter required  <Is an interpreter required>	
Is there a current Mental Health Treatment Plan in place  <Is there a current Mental Health Treatment Plan in place>	
Emergency contact name  <Emergency Contact Name>	Relationship to person  <Emergency Contact - Relationship to person>	
Phone number  <Emergency Contact Phone Number>	Role of emergency contact  <Role of Emergency Contact>	

REFERRAL NOTES

Mental health diagnosis  <Mental Health Diagnosis>

Medications

<CurrentRx>

KEY GOALS
(What else do we need to know to support the individual moving forward)

What are the individual's key goals and hopes for engaging in the program?  <Key goals and hopes for engaging in program>

What are the individual's strengths and support systems?  <Strengths and support systems>

Is there anything you or the individual would like us to know about how we can best meet their needs (e.g. cultural needs; medical; medication issues, developmental, functional; living skills, social; emotional; trauma, abuse and neglect; etc:  <Any other relevant information, e.g. social, abuse etc>

IDENTIFIED AREAS OF SUPPORT REQUIRED

Emotional Wellbeing:  <Support required: Emotional Wellbeing>

Physical Health/ADLs:  <Support required: Physical Health/ADLs>

Social Connection:  <Support required: Social Connection>

Food, Diet, or Lifestyle:  <Support required: Food, Diet or Lifestyle>

Housing or Social Supports:  <Support required: Housing or Social Supports>

Financial Needs & Benefits:  <Support required: Financial Needs & Benefits>

Families & Relationships:  <Support required: Families & Relationships>

Employment & Education:  <Support required: Employment & Education>

Domestic Violence:  <Support required: Domestic Violence>

NDIS & My Aged Care:  <Support required: NDIS & My Aged Care>

SAFETY ALERTS - Are there any risk factors we should be aware of when visiting the home/client, e.g. is there a history of aggressive behaviour? <Safety Alerts: Are there any risk factors to be aware of>
If yes, please specify: <If yes, please specify or attach risk assessment>

Risk of harm to self:  <Risk of harm to self>

Risk of harm to others:  <Risk of harm to others>

Mental Health Order:  <Mental Health Order>

Enduring Power of Attorney:  <Enduring Power of Attorney>

Not able to make own decision/Guardianship:  <Not able to make own decision/Guardianship>

Orders relating to children:  <Orders relating to children>

Intervention Order/AVO:  <Intervention Order/AVO>

Triggers/Trauma:  <Triggers/Trauma>

Current treatment plans: <Please attach any current treatment plans>

Medical History

<SelectedPMH>

Plus Social Clinical Care Coordination is a comprehensive, high intensity clinical support service for people age 18+ who experience the impact of severe mental illness and are not currently case-managed or accessing Gold Coast Health mental health services. Up to 26 weeks clinical care coordination and wellbeing program that is structured, recovery and goal orientated focused on creating significant improvements in quality of life, health and wellbeing.