FM537 Mental Health Nursing in Brisbane North Referral form The Mental Health Nursing in Brisbane North (MHNiB) program delivers clinical care coordination and treatment services for people with severe mental illness and complex health issues being managed in primary care settings. The mental health nurses (MHN’s) provide specialised support to GP’s and community based psychiatrists by consulting and collaborating with them on the patient’s clinically related needs and goals identified in the MHTP, coordinating access to and liaising with other health providers and community support agencies, providing active follow-up and reviews of the patients mental and physical health, delivering psycho education, administering, monitoring and ensuring compliance with medications and liaising with family and carers as appropriate. To be eligible for MHNiB the patient must be 18 years and over and meet all of the following criteria (please tick): MHNiB eligibility criteria The person has a diagnosed/provisionally diagnosed mental disorder which is severe in nature and related complex health needs, and The mental disorder significantly impacts at least 2 areas of social, personal and/or occupational functioning, and The person has, or is at risk of developing, a physical health problem, and The mental disorder has resulted in hospital treatment in the previous 2 years or there is a risk of hospitalisation within the next 12 months if clinical care by a MHN is not provided, and The patient is expected to need ongoing treatment and management of their mental disorder over the next 2 years, and A primary care based GP or psychiatrist is the main person responsible for the persons clinical mental health care and has initiated/completed an initial mental health treatment plan If the patient has psychosocial disability please refer them to Partners in Recovery or the National Disability Insurance Scheme when it becomes available in your region. Referral details Patient name Gender Male Female Other or not stated Date of Birth Patient address Phone number Home: Mobile: Work: GP Mental Health Treatment Plan is attached Yes (note this is a requirement) Reason for referral: Current Medication: Page 1 of 3 The Mental Health Nursing in Brisbane North (MHNiB) program is funded by Brisbane North PHN. Brisbane North PHN gratefully acknowledges the financial and other support from the Australian Government Department of Health General practitioner / psychiatrist details Practitioner name Practice name Phone number Fax number Email address As the referring medical practitioner I confirm that: I am satisfied the patient understands that by referring them to the MHNiB program their personal information will be provided to the MHNiB provider, that the provider will make contact with them directly, and they have provided informed consent for this referral. General practitioner / psychiatrist signature: Date: Please fax this referral form and the GP Mental Health Treatment Plan to: Please refer to the MHNiB provider in the region in which the patient resides. Please see attached for a list of the Brisbane North PHN sub-regions and suburbs. x For Moreton Bay North sub-regions, fax Morayfield Psychology Centre on 1300 933 033. x For Moreton Bay South and Brisbane North sub-regions, fax Footprints on 1300 027 319. x For Brisbane Inner City and Brisbane West sub-regions, fax Toowong Private Hospital on 1300 103 458. If you wish to speak to a MHNiB provider please call 1300 522 822 Office Use Only Date referral received: Database updated: YES NO GP Mental Health Treatment Plan: Care Coordinator assigned: YES NO YES NO Psychiatrist / GP notified of outcome: YES NO Consent: YES NO Page 2 of 3 The Mental Health Nursing in Brisbane North (MHNiB) program is funded by Brisbane North PHN. Brisbane North PHN gratefully acknowledges the financial and other support from the Australian Government Department of Health Appendix: Brisbane North PHN sub-regions and suburbs Moreton Bay North. Refer to Morayfield Psychology Centre on fax 1300 522 822 Banksia Beach Caboolture Linville Neurum Toorbul Beachmere Caboolture South Meldale Ningi Upper Caboolture Bellara D’Aguilar Moodlu Rocksberg Villeneuve Bellmere Delaneys Creek Moorina Royston Wamuran Bongaree Elimbah Morayfield Sandstone Point Welsby Booroobin Godwin Beach Mount Delaney Sandy Creek White Patch Bracalba Harlin Mount Kilcoy Stanmore Woodford Burpengary Hazeldean Mount Mee Stony Creek Woorim Burpengary East Kilcoy Narangba Redcliffe – North Lakes. Refer to Morayfield Psychology Centre on fax 1300 522 822 Clontarf Griffin Mango Hill Newport Rothwell Dakabin Kallangur Margate North Lakes Scarborough Deception Bay Kippa Ring Murrumba Downs Redcliffe Woody Point Pine Rivers. Refer to Footprints on fax 1300 XXX XXX Albany Creek Cedar Creek Highvale Mount Glorious Samford Village Arana Hills Clear Mountain Joyner Mount Nebo Samsonvale Armstrong Creek Closeburn King Scrub Mount Pleasant Strathpine Bray Park Dayboro Kobble Creek Mount Samson Warner Brendale Draper Kurwongbah Ocean View Whiteside Bunya Eatons Hill Lacey’s Creek Petrie Wights Mountain Camp Mountain Everton Hills Lawnton Samford Valley Yugar Cashmere Ferny Hills Brisbane North. Refer to Footprints on fax 1300 XXX XXX Aspley Carseldine Fitzgibbon Nudgee Stafford Bald Hills Chermside Geebung Nudgee Beach Stafford Heights Banyo Chermside West Gordon Park Nundah Taigum Boondall Deagon Kedron Pinkenba Virginia Bracken Ridge Eagle Farm McDowall Sandgate Wavell Heights Bridgeman Downs Everton Park Northgate Shorncliffe Zillmere Brighton Brisbane West. Refer to Toowong Private Hospital on fax 1300 XXX XXX Anstead Enoggera Reservoir Kenmore Mount Coot-tha Taringa Bellbowrie Ferny Grove Kenmore Hills Pinjarra Hills The Gap Brookfield Fig Tree Pocket Keperra Pullenvale Upper Brookfield Chapel Hill Gaythorne Mitchelton St Lucia Upper Kedron Enoggera Indooroopilly Moggill Brisbane Inner City. Refer to Toowong Private Hospital on fax 1300 XXX XXX Albion Bowen Hills Hendra Newmarket Teneriffe Alderley Brisbane City Herston Newstead Toowong Ascot Clayfield Kelvin Grove Paddington Wilston Ashgrove Fortitude Valley Lutwyche Petrie Terrace Windsor Auchenflower Grange Milton Red Hill Wooloowin Bardon Hamilton New Farm Spring Hill Page 3 of 3 The Mental Health Nursing in Brisbane North (MHNiB) program is funded by Brisbane North PHN. Brisbane North PHN gratefully acknowledges the financial and other support from the Australian Government Department of Health.