Psychiatric History: (Personal and/or Family History) ☐ Antidepressant ☐ Benzodiazepines & anxiolytics *Medications: ☐ Phenothiazine’s & tranquillisers ☐ Mood stabilisers ☐ Other or attach copy of medication list * Outcome tool: K10 DASS 21 EPDS (perinatal) Attach a copy of completed tool D A S Result/s: Mental State Examination (If other please provide details in comments) Mood: Appearance & General Behaviour Normal Other : Normal Other : Thinking: Affect Normal Other : Normal Other : Perception Sleep Normal : Normal Other : Cognition Appetite Normal Other : Normal Other : Attention /Concentration Motivation /Energy Normal Other : Normal Other : Memory Judgement Normal Other : Normal Other : Insight: Anxiety Symptoms Normal : Normal : Orientation: Speech Normal : Normal Other : Risk Assessment Yes No Yes No * * Suicidal Ideation: Suicidal Intent / Plan: Yes No Yes No * * Previous Attempt: Access to Methods: * * Yes No Yes No History of Self Harm: Risk to Others: * * Yes No Yes No Lives Alone: Drug or Alcohol use: * If yes to any of the above provide relevant details: Identify and provide details of any protective factors or key support contacts: Provided numbers for immediate assistance: Yes No E.g., Rural & Remote Mental Health Service 13 14 65, Life Line 13 11 14 Date of follow up GP apt: Forensic History: Medical Conditions/Allergies: Relevant Family History:
Psychiatric History: (Personal and/or Family History) *Medications: ☐ Antidepressant ☐ Benzodiazepines & anxiolytics ☐ Phenothiazine’s & tranquillisers ☐ Mood stabilisers ☐ Other or attach copy of medication list * Outcome tool: Attach a copy of completed tool K10 DASS 21 EPDS (perinatal) Result/s: D A S Mental State Examination (If other please provide details in comments) Mood: Normal Other : Appearance & General Behaviour Normal Other : Thinking: Normal Other : Affect Normal Other : Perception Normal : Sleep Normal Other : Cognition Normal Other : Appetite Normal Other : Attention /Concentration Normal Other : Motivation /Energy Normal Other : Memory Normal Other : Judgement Normal Other : Insight: Normal : Anxiety Symptoms Normal : Orientation: Normal : Speech Normal Other : Risk Assessment * Suicidal Ideation: Yes No * Suicidal Intent / Plan: Yes No * Previous Attempt: Yes No * Access to Methods: Yes No * History of Self Harm: Yes No * Risk to Others: Yes No * Lives Alone: Yes No * Drug or Alcohol use: Yes No * If yes to any of the above provide relevant details: Identify and provide details of any protective factors or key support contacts: Provided numbers for immediate assistance: Yes No E.g., Rural & Remote Mental Health Service 13 14 65, Life Line 13 11 14 Date of follow up GP apt: Forensic History: Medical Conditions/Allergies: Relevant Family History:
My-Coordinated-Care_Referral-Form_FINAL.docx