Wesley Mission Queensland
Mental Health Services
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 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. Info discussed pt

Client or Parent/Guardian/Carer consents to Referral Patient Consent

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

Referral Date  Miscellaneous.Date

REFERRER DETAILS

Referrer's role	Referrer's Role	
Referrer's name	Treating Doctor.Name	
Referrer's email	Treating 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: Eligibility: benefit
Mild to moderate mental health needs: Eligibility: Mild to
Identifies with the LGBTIQAP+ community and/or are questioning sexuality or gender identity, requiring culturally specific support: Eligibility: LGBTIQA
Requiring structured psychological interventions (clinical supports): Eligibility: Psychol
Requiring psychosocial supports: Eligibility: Psychos
Current suicidal ideation or at risk of suicide: Eligibility: Suicide

PATIENT DETAILS

RE: Patient Demographics.Full Name	DOB: Patient Demographics.DOB	
Gender  Patient Demographics.Gender	Other gender identity (if applicable)  Other Gender	
Address: Patient Demographics.Address	Experiencing homelessness Homelessness	
Home phone: Patient Demographics.Phone (Home)	Mobile phone: Patient Demographics.Phone (Mobile)	
Is it safe to call/text the client: Safe to call	Health Care/Pension Card  Health Care/Pension
Expiry date: Expiry date	
Aboriginal &/or Torres Strait Islander status  A&TSI	Culturally or Linguistically Diverse (CALD)  CALD
Language spoken at home  Language
Is an interpreter required  Interpreter	
Support contact name  Support name	Support  contact's relationship to client Relationship	
Support contact's phone number  Support number		

ADDITIONAL INFORMATION

Reason for referral  Reason for referral
	
Barriers to accessing service  Barriers
	
Is there a risk of harm to self or others Risk of harm

If yes, please provide details Risk details

Has the client had thoughts of self-harm or suicide within the past four weeks Self harm

**Please note this is not a crisis service. If assessed at very 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

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