Residential Aged Care Home Psychological Therapy

This referral form is for the Residential Aged Care Home Psychological Therapy Program, available to residents of the following Mackay facilities: Ozcare St Elizabeth Villa, St Francis of Assisi, Good Shepherd Lodge, Kerrisdale Gardens, and Resthaven on Quarry.

The program is designed for residents experiencing a non-acute mental health condition or those at risk of developing a mental illness, providing short-term, goal-focused psychological strategies tailored to their needs.

If the person has acute mental health needs, refer to Acute Care Team or Child Youth Mental Health Service via 1300 64 2255

Residential Aged Care Home Psychological Therapy 20260109

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Referrer Details

Referrer Name:*

Role/Relationship:*

Organisation Name:*

Provider Number:

Contact Number:*

Fax Number:

Referrer Email:*

Resident Details

Duration of Residence in RACH

Full Name:*

Date of Birth:*

DD slash MM slash YYYY

Gender:*

Address:*

Street Address Country

Phone:*

Email:*

Health Care Card?*

Yes

Pension Card?*

Yes

Dept Veterans Affairs (DVA) Card?*

Yes

Does the person identify as Aboriginal or Torres Strait Islander?*

Yes

Proficiency in spoken English:*

Very Well

Well

Not Well

Not at all

Interpreter required?*

Yes

If yes, language:

Referral Information

Reason for referral:*

Is there a mental health diagnosis?*

Yes

If yes, please specify:

Are there health professionals currently involved in the consumer’s care?*

Yes

If yes, please provide details:

Is the individual currently taking medication?*

Yes

If yes, please attach the medications chart.

Drop files here or

Max. file size: 1 GB.

Is there a history of alcohol and/or drug use?*

Yes

If yes, please provide details:

Is there history of suicide and/or self harm?*

Yes

If yes, please provide details:

Is there a history of aggression or violence?*

Yes

If yes, please explain:

Is there a concern regarding safety, vulnerability, and/or domestic violence?*

Yes

If yes, please provide details:

Is this person a risk to themselves or others?*

Yes

If yes, please explain:

Capacity to consent: Does the resident have capacity to consent to health care?

Yes

Unsure / Capacity fluctuates

If you ticked “No” or “Unsure / Capacity fluctuates”, please complete the section below: Authorised Decision-Maker (Health Care).

Full name of Authorised Decision-Maker

First Last

Relationship to resident

Legal authority (select one)

Enduring Power of Attorney (Health / Personal Matters)

Guardian (QCAT appointment – Queensland)

Statutory Health Attorney (Queensland)

Phone

Do you confirm that you are legally authorised to make health care decisions for the resident under Queensland law?*

Yes

Do you consent to CARE4MH providing mental health services to this patient?*

Yes

These services may include, but are not limited to:

Mental health assessment and formulation.
The provision of evidence-based psychological therapies.
Liaison and collaboration with the resident’s aged care home, general practitioner (GP), hospitals, and other relevant health or support services, where appropriate.

I understand that:

All services are provided by appropriately qualified and registered clinicians in accordance with professional standards and Queensland legislation.
Care is delivered in the resident’s best interests and is informed by their needs, preferences, and clinical presentation.
Participation in psychological therapy is voluntary, and the resident (or authorised decision-maker) may decline or discontinue services at any time without penalty.
Consent may be reviewed if there is a change in the resident’s capacity to consent, their circumstances, or the scope of services being provided.

Do you confirm that you understand the information above and consent to CARE4MH providing mental health treatment to the resident in accordance with Queensland law.*

Yes

Consent To Collection and Sharing Information

In accordance with the Privacy Act 1988 (Cth) and the Information Privacy Act 2009 (Qld), CARE4MH requires consent to collect and disclose personal information for the purposes of this referral and consent form.

Do you consent to CARE4MH sharing relevant information with Local Health District services, the resident’s emergency contact, and other involved health or support providers to enable coordination of care and delivery of mental health services.

Do you consent?*

Yes

Ongoing Consent & Withdrawal

I understand that this consent applies to current and future services provided by CARE4MH, unless one of the following occurs:

The resident’s decision-making capacity changes.
A different authorised decision-maker is appointed.
The nature or extent of services is substantially altered.
Consent is revoked.

Do you consent?*

Yes

Consumer name or authorised decision-maker:*

Consumer signature or authorised decision-maker:*

Date:

DD slash MM slash YYYY

By signing below, 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 partner agencies.

Referrer name:*

Referrer signature:*

Date:

DD slash MM slash YYYY

Phone

This field is for validation purposes and should be left unchanged.

Residential Aged Care Home Psychological Therapy