RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>			
			
Does the patient consent for their personal information to be collected and used for the provision of services?

This includes making personal information available for the purpose of intake and access to the most appropriate service.

Note - Patient must consent to provision of data for this service to proceed.	<<Does the patient agree to the provision of data?>>	

Patient Details
First Name:	<<Patient Demographics:First Name>>	
Last Name:	<<Patient Demographics:Surname>>	
Date of Birth:	<<Patient Demographics:DOB>>	
Is date of birth Accurate:	<<Is date of birth accurate? >>	
Gender:	<<Patient Demographics:Gender>>	
Mobile:	<<Patient Demographics:Phone (Mobile)>>	
Phone:	<<Patient Demographics:Phone (Home)>>	
Address:	<<Patient Demographics:Address Line 1>>	
City:	<<Patient Demographics:City>>	
Postcode:	<<Patient Demographics:Postcode>>	
State:	<<Patient Demographics:State>>	
Ethnicity:	<<Patient Demographics:Ethnicity>>	
Aboriginal and/or Torres Strait Islander:	<<Patient Demographics:ATSI>>	
Main Language Spoken:	<<Patient Demographics:Language Spoken>>	
English Skill:	<<English Skill>>	
Is an interpreter required:	<<Patient Demographics:Requires Interpreter>>	

Referral Details
Referrer Name:	<<Doctor:Name>>	
Referrer Email:	<<Practice/Location:E-mail>>	
Referring Practice:	<<Practice/Location:Name>>	
Service Type:	<<Service type>>	
Service Provider:	<<Provider>>	

Ipswich Head to Health	
Ipswich Head to Health offers a welcoming, soft entry point to engagement, assessment, and treatment for people who are seeking support for their mental health and wellbeing.
The service operates as a no-wrong-door for anyone seeking help, and can provide on-the-spot care, advice, and support provided by mental health professionals, without needing a prior appointment.
The service can provide assessment (including the use of the Initial Assessment and Referral Decision Support Tool), immediate, short and medium term episodes of care, and service navigation to connect people to ongoing care. All services provided through Kingaroy & Ipswich Head to Health are no-cost.
Ipswich Head to Health also work collaboratively with the Head to Health Intake and Assessment Phone Service to enable smooth transfers of information and transition between services.
Please note: Ipswich Head to Health is currently providing pop-up services from this site while fit-outs of the permanent site are being completed. Services are expected to transition to the permanent site within the Nicholas Street Precinct in early 2024.
Eligibility
Anyone seeking mental health support is able to access this service. While the service is targeted at adults, young people presenting to the service will be supported through the provision of information to navigate and access services that may be most appropriate for responding to their needs.
Referral Pathways
People are able to access services through any available channel, including via referral from GPs, and health professionals, by calling the Head to Health Assessment and Referral Phone Service, or through service walk-ins.	

Reason for Referral
<<Reason for referral?>>	

Diagnosis
<<Diagnosis>>	

Additional Referral Details
Has a GP Mental Health Treatment Plan been completed?:	<<GP Mental Health Treatment Plan Completed?>>	
Active Suicide Referral Flag:	<<Is there an active suicide risk for this client?>>	

Additional comments regarding this referral
<<Additional comments>>	

While RHealth will assist in the carriage of this referral to an appropriate provider, RHealth does not take responsibility or guarantee the provision of service to this client, or the acceptance of this referral by the selected or alternate service provider.

PHN Site Code: DDWMPHN
Version 7.5
Do not remove site code	

Insert Mental Health Care Plans or additional information below this text.