headspace YOUTH EARLY PSYCHOSIS PROGRAM REFERRAL

headspace YOUTH EARLY PSYCHOSIS
PROGRAM REFERRAL FORM
hYEPP referrals can be made by contacting headspace Joondalup or headspace Osborne Park.
Referrals can be made directly from a tertiary level public health and mental health services to the
Mobile Assessment Treatment Team (MATT) by submitting this form by fax to 9301 1325 or email to
[email protected]
Name of young person
Date of Referral
Male
Gender
Female
Other
___ / ___ / _____
D.O.B. ___ / ___ / _____
*client must be between 12 to 25 to be eligible
Is the young person of Aboriginal and or Torres Strait Islander descent? (tick as appropriate)
No
Yes, Aboriginal
Yes, Torres Strait Islander
Country of Birth
Language spoken at
home
Interpreter required
Yes
No
Street name: _________________________________________________
Address
Suburb: ________________________________ Postcode: ___________
Mobile: _______________________ Home Phone: __________________
BINDING MARGIN – NO WRITING
Contact details
Email: ____________________________________
Preferred contact
Mobile
Home Phone
Email
Next of Kin/Emergency
contact name
Relationship
Phone
GP name
Practice
Name
GP contact details
Can we contact the GP?
Phone: ______________________
Yes
Referrer name
No
Post
Email: ________________________
Unsure
Referring tertiary public service
Email
Position
Phone
Reason for referral (presenting issues)
Details:
Current mental health symptoms
Details:
When was the young person first recognised to have the identified presenting issues?
Details:
MATT headspace Youth Early Psychosis Program (hYEPP)
t: 08 9301 8999 f: 08 9301 1325 e: [email protected]
Sanori House, 126 Grand Boulevard, Joondalup, WA 6027
http://blackswanhealth.com.au/services/hyepp/
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headspace YOUTH EARLY PSYCHOSIS
PROGRAM REFERRAL FORM
History of prodromal symptoms?
Yes
No
Uncertain
Estimated length of Duration of Untreated Psychosis (DUP)?
Evidence of negative symptoms
How have these mental health issues impacted on functioning?
Details:
BINDING MARGIN – NO WRITING
Level of Insight (tick as appropriate)
Excellent
understands diagnosis and need for treatment
Moderate
accepts something is wrong and is willing to accept treatment
Poor
accepts something is wrong but is unwilling to accept treatment
None
does not perceive self as having an illness
Details:
Previous contact with other mental health services/practitioners
Details:
Yes
No
Uncertain
Previous psychiatric diagnosis
Details:
Yes
No
Uncertain
Previous hospitalisations
Details:
Yes
No
Uncertain
Previous medications
Details:
Yes
No
Uncertain
Current medications
Details:
Yes
No
Uncertain
Other physical health issues / illnesses
Details:
Yes
No
Uncertain
MATT headspace Youth Early Psychosis Program (hYEPP)
t: 08 9301 8999 f: 08 9301 1325 e: [email protected]
Sanori House, 126 Grand Boulevard, Joondalup, WA 6027
http://blackswanhealth.com.au/services/hyepp/
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headspace YOUTH EARLY PSYCHOSIS
PROGRAM REFERRAL FORM
Relevant findings of any baseline blood tests e.g. metabolic, ECG, CT / MRI Head (if applicable)
Details:
Date completed : ___ / ___ / _____
Family psychiatric history (e.g. mental illness / addiction / suicide)
Details:
BINDING MARGIN – NO WRITING
Social situation (e.g. family relationships, level and nature of supports, accommodation, study /
employment, finances)
Details:
Substance use (e.g. type, amount, frequency)
Past
Current
Yes
Yes
No
No
History of criminal charges?
Details:
Yes
No
Current or pending charges / issues?
Details:
Yes
No
History of self-harm / suicidality?
Details:
Yes
No
Current thoughts / plans / intent?
Details:
Yes
No
History of violence?
Details:
Yes
No
Current thoughts / plans / intent?
Details:
Yes
No
History of risk from and/or to others?
Details:
Yes
No
Details:
MATT headspace Youth Early Psychosis Program (hYEPP)
t: 08 9301 8999 f: 08 9301 1325 e: [email protected]
Sanori House, 126 Grand Boulevard, Joondalup, WA 6027
http://blackswanhealth.com.au/services/hyepp/
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headspace YOUTH EARLY PSYCHOSIS
PROGRAM REFERRAL FORM
Mental Health Act status
Community Treatment Order
Involvement with other support services?
Details:
Voluntary
Involuntary
Yes*
No
* If Yes, expiry date ___ / ___ / _____
Yes
No
BINDING MARGIN – NO WRITING
Interim Plan (any interim arrangements in place for young person’s care pending outcome of referral?)
Details:
CONSENT TO REFERRAL
The young person has been assessed and meets the eligibility criteria for a referral to Black
Swan Health
Yes
No
The young person is aware of the referral
Yes
No
The young person is agreeable of the referral
Yes
No
Signature:
_____________________________
Print Name:
_____________________________
Date: ___ / ___ / ______
Office use only
Confirmation sent by (name) __________________________ on (date) ___ / _____ / ______
MATT headspace Youth Early Psychosis Program (hYEPP)
t: 08 9301 8999 f: 08 9301 1325 e: [email protected]
Sanori House, 126 Grand Boulevard, Joondalup, WA 6027
http://blackswanhealth.com.au/services/hyepp/
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