Mental Health Services
Direct Referral Form

Forward completed Referral via Medical Objects to: MS42140001L
or Fax 07 3539 6444

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 Wesley Mission Queensland Intake Team to deliver intake services. This information will be used to assess initial eligibility for Mental Health Programs and WMQ will contact the person for intake if eligible.

Please indicate the information in this form has been discussed with, and provided to the client and the client is aware deidentified data is shared with GCPHN and Australian Department of Health and Aged Care for research and evaluation purposes to improve quality and access to care.  <<Consent info has been discussed/provided to client>>

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

Consent to sharing details below with additional services such as Head to Health  <<Consent to sharing details with additional services>>

REFERRAL DATE: <<Miscellaneous:Date (short)>> 

REFERRER DETAILS 
Referrer's role	<<Referrer's Role>>	
Referrer's name	<<Doctor:Name>>	
Referrer's email	<<Doctor:E-mail>>	
Practice name	<<Practice:Name>>	
Practice address	<<Practice:Address>>	
Practice phone no	 <<Practice:Phone>>	
Practice fax no	<<Practice:Fax>>	

ELIGIBILITY
Please select any that apply:
•	Benefit from short term intervention (required): <<Eligibility: Benefit from short term intervention (req)>>
•	Mild to moderate mental health needs: <<Eligibility: Mild to moderate mental health needs>>
•	Identifies with the LGBTIQAP+ community and/or are questioning sexuality or gender identify, requiring culturally specific support: <<Eligibility: LGBTIQAP+/questioning sex/gender id>>
•	Requiring structured psychological interventions (clinical supports): <<Eligibility: Requires structured psych interventions>>
•	Requiring psychosocial supports: <<Eligibility: Requiring psychosocial supports>>
•	Current suicidal ideation or at risk of suicide: <<Eligibility: Current suicidal ideation/ at risk of suicide>>
CLIENT DETAILS
All information below is critical to support the triage and intake process. Please complete all fields.

RE: <<Patient Demographics:Full Name>> 	DOB: <<Patient Demographics:DOB>> 	
Gender  <<Patient Demographics:Sex>>
Pronouns <<Preferred client pronouns>>	Other gender identify (if applicable) <<Client - other gender Identity (if applicable)>>	
Address  <<Patient Demographics:Full Address>>	Experiencing homelessness <<Is client experiencing homelessness>>	
Home phone number  <<Patient Demographics:Phone (Home)>> 	Mobile phone number  <<Patient Demographics:Phone (Mobile)>>	
Is it safe to call/text the client? <<Is it safe to call/text the client?>>	Health Care/Pension Card  <<Health Care/Pension Card>>

Expiry date <<Health Care/Pension Card expiry date>>	
Aboriginal &/or Torres Strait Islander status  <<Identifies as Aboriginal and/or Torres Strait Islander>>	Culturally or Linguistically Diverse (CALD)  <<Culturally or Linguistically Diverse (CALD)>>
Language spoken at home <<Language spoken at home>>
Is an interpreter required  <<Is an interpreter required>>	
Support contact name  <<Support contact name>>	Relationship to client: <<Support contact - Relationship to client>>	
Support contact phone number  <<Support contact - Phone number>>		

CLINICAL INFORMATION

Reason for referral <<Reason for referral>>
	
Barriers to accessing service: <<Barriers to accessing service>>
	
Is there a risk of harm to self or others <<Is there a risk of harm to self or others>>
If yes, please provide details:  <<If yes, please provide details>>

Has the client had thoughts of self-harm or suicide within the past four weeks?  <<Thoughts of self-harm/suicide within past 4 weeks?>>

 **Please note this is not a crisis service. If assessed at high risk of harm, please contact Emergency Services on 000 or Acute Care Team on 1300 642 255.
	
Other services being accessed, relevant diagnoses and additional notes: 
<<Other services/ relevant diagnoses/additional note>>

Please attach any additional information or documents if required and return to the Intake Team (contact details above).