Mental Health Treatment Plan Review

This form is specifically for patient's who have previously been provided a Mental Health Treatment Plan by our GP previously.

MHTP Review

Have you previously been provided a MHTP from our GP?

YesNo

This form is only for patient's who are due for a review of an existing MHTP created by our GP.

Contact and Demographic details (HCP to complete)

GP name

GP Provider Number

GP phone *

GP practice name *

GP fax *

GP address *

Patient details (patient to complete)

First Name *

Last Name *

Date of birth *

Email Address *

Phone *

K10 test (patient to complete)

We’ll ask you 10 questions about how you’ve been feeling over the past 4 weeks. This will take around 5-10 minutes of your time. This test can help you determine your level of stress. The test will give you support and resources based on the results.

In the past 4 weeks... How often did you feel tired out for no reason?

In the past 4 weeks... How often did you feel so nervous that nothing could calm you down?

In the past 4 weeks... How often did you feel so restless you could not sit still?

K10 result: (GP to complete)

Relationship (GP to complete)

This person has been:

my patient sincea patient at this practice sinceN/A - not applicable

date since:

Plan (GP to complete)

Goals set:

Goals comments

Intervention/relapse prevention plan(if appropriate at this stage) Consider: • Identify warning signs from past experiences • Note arrangements to intervene in case of relapse or crisis • Other support services currently in place • Note any past effective strategies

Psycho-education provided if not already addressed in “treatments and interventions” above?

YesNo

Plan added to the patient’s records?

YesNo

On completion of the plan, the GP may record (tick boxes below) that s/he has:

discussed the assessment with the patientdiscussed all aspects of the plan and the agreed date for reviewoffered a copy of the plan to the patient and/or their carer (if agreed by patient)

Date completed

Referral (GP to complete)

This referral is for

4 follow up sessions

Referral sent to:

TalkedOther

If patient has preference of their own psychologistPlease enter name of pyschologist here.

Record of Patient Consent (patient to complete)

If eligible for Medicare, DVA or concessional billing do you give permission to bill? *

YesNo

If Bulk Billed, I assign my rights to the Healthcare professional who rendered the services. If eligible for a Mixed billed consultation a medicare rebate will be processed and deposited into your nominated bank account directly by Medicare. *

YesNo

I, agree to information about my health being recorded in my medical file and being shared between the General Practitioner and other health care providers involved in my care, as nominated above, to assist in the management of my health care. I understand that I must inform my GP if I wish to change the nominated people involved in my care.

I understand that as part of my care under this Mental Health Treatment plan, I should attend the General Practitioner for a review appointment at least 4 weeks after but within 6 months after the plan has been developed.

I consent to the release of the following information to the following carer/support and emergency contact persons

Patient name

Patient signature

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Record of Healthcare Professional (GP to complete)

I, have discussed the plan and referral(s) with the patient.(Full name of GP) (Signature of GP)

GP name

GP signature

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GP date