Mental Health Referral Form
Secure Fax: (02) 8208 9941 or HealthLink EDI: wntwstmh

Patient Information:	
First name		Last name	
Address		Suburb	Postcode	
Gender	☐	M	☐ F	DOB 	/ 	/ 		Phone number	
Medicare number		Country of birth	
Main language spoken at home	☐	English ☐ Arabic ☐ Cantonese ☐ Mandarin ☐ Hindi
☐	Spanish ☐ Italian ☐ Other (please specify)	
Spoken English level	☐	Very Well ☐ Well ☐ Not Well ☐ Not at all	☐	Interpreter Required	
Aboriginal and/or Torres Strait Islander	☐	No ☐ Yes, Aboriginal ☐ Yes, Torres Strait Islander ☐ Both ☐ Unknown	
Marital status	☐	Never married ☐ Married/De facto ☐ Widowed ☐ Divorced ☐ Separated ☐ Unknown	
Homelessness	☐	Stable housing ☐ Short-term/emergency accommodation ☐ Sleepingrough	
Labour force status	☐	Employed ☐ Unemployed ☐ Not in the labour force ☐ Unknown	
Employment type	☐	Full time ☐ Part time/Casual ☐ Not applicable ☐ Unknown	

Source of income	☐	Paid employment ☐ Nil income ☐ Disability support pension ☐Other pension
☐	Compensation payments   ☐ Other (super, investments etc.)	☐ Unknown	
Health Care Card	Number:		☐	No	
Financial hardship	☐	No ☐ Yes	
NDIS registered	☐	No   ☐Yes	Number:	
Mental Health Presentations	

Presenting issues	
Principal diagnosis
Anxiety disorders:
☐	Panic disorder
☐	Agoraphobia
☐	Social phobia
☐	Generalised anxiety	
☐	OCD
Depressive disorders:
☐	Major depression
☐	Depressive symptoms
☐	Bipolar disorder	
☐	Adjustment disorder
☐	Oppositional defiant
☐	Personality disorder
☐	Conduct disorder
☐	Complex PTSD	
☐	Alcohol dependence
☐	Drug dependence
☐	Schizophrenia
☐	Other: 		
Severity	☐	Mild	☐ Moderate	Severe:	☐	Acute or ☐ Complex		
Psychotropic medication
(please tick all that apply)		☐	None
☐	Hypnotics and sedatives
☐	Psychostimulants and nootropics	☐	Antidepressants
☐	Antipsychotics
☐	Anxiolytics	
Outcome tool score	☐ K10	☐ K5
(Please attach form)	☐	SDQ	☐	Other: 		
Previous mental or physical health history or treatment	

Priority Group	
Is this person currently at high risk of suicide? ☐ Yes ☐ No	
☐	Child (0-12 years)	☐ Young adult (13-25 years)	☐ CALD	☐ Aboriginal and/or Torres Strait Islander
☐	Refugee/Asylum Seeker ☐ Severe and complex mental illness   ☐ Peri-natal	☐ LGBTIQ	☐ Elderly	
Treatments	
Referred for which strategies	☐	Psychological therapy	☐ Psychiatric services
☐	Suicide prevention service	☐ Other: 		
Preferred WentWest Provider or Service	☐	Navin Goonniah – mindovermatter.net.au	
Additional Information e.g. anger, self-harm, grief	
	
Referrer Details	
Name		Profession		
Organisation type		Phone number		

Address		Fax number		
		HealthLink EDI		
***Consent: Patient or parent/guardian for a child must be completed for the referral to be accepted***	

Referrer confirms that the patient understands and consents to the following:

1.	Understands that the information provided in this referral is required to determine eligibility for services with WentWest.
2.	Gives consent for services to be provided by suitable programs, as requested on this referral.
3.	Gives permission for the exchange of this information between Health Professional and other agencies for the purpose of coordination of care.
4.	Consents to de-identified information to be used for statistical purposes for WentWest and the Department of Health.

Referrer name: 		Referrer signature:  	
(include name for forms sent via HealthLink)
Date:  		
Please ensure the following is complete before sending to WentWest:	

•	Patient contact information including phone number
•	Financial and priority group information including Health Care Card number
•	Mental Health Treatment Plan, outcome tool or medication list (psychiatric service is attached)
•	Consent section above.

Send completed form and Mental Health Treatment Plan via:
Secure Fax: (02) 8208 9941 or HealthLink EDI: wntwstmh	

WentWest Limited
Level 1, 85 Flushcombe Road
Blacktown NSW 2148
PO Box 5, Blacktown Post Shop NSW 2148

T  02 8811 7100
F  02 9622 3448
E wentwest@wentwest.com.au ACN 099 255 106
ABN 80 099 255 106

WentWest operates as Western Sydney Primary Health Network.