Psychological Therapy & Clinical Care Coordination Referral Form

A rapid-access psychological therapy service providing moderate to high-intensity support, delivering person-centred care to enhance mental health and overall wellbeing.

A care coordination approach to provide holistic care and treatment for people with high acuity, severe & persistent mental health needs, which impacts daily function.

Referrer Details

Consumer Details

Emergency Contact

Contact in the event of an emergency or if the referred person is unavailable. If the consumer is a child, provide the details of the legal parent or guardian.

Referral Information

Note: It is not necessary to complete the Referral Information section if a Mental Health Treatment Plan (MHTP) or Child Treatment Plan (CTP) accompanies this referral document and contains the information below

Consent To Share Information

In accordance with the Privacy Act 1988 and the Information Privacy Act 2009, your consent is required for the release of information related to this application.

By signing this form, you consent CARE4MH to collect and share information relevant to your application with relevant Local Health District services, your emergency contact, and other service providers involved in your care. This consent ensures that all parties can collaborate effectively to support your mental health needs.

The referrer agrees that all information submitted in this referral is an accurate and complete, reflecting the applicant’s support needs. This information is essential for Care4MH to effectively fulfill its duty of care to consumers, staff and parter agencies.