GP MENTAL HEALTH Treatment PLAN Version for children – Notes: This form is designed for use with the following MBS items. Users should be familiar with the most recent item definitions and requirements. MBS ITEM Number: 2700 2701 2715 2717 Major headings are bold; prompts to consider lower case. Response fields can be expanded as required. Underlined items of either type are mandatory for compliance with Medicare requirements. This document is not a referral letter. A referral letter must be sent to any additional providers involved in this mental health treatment plan. CONTACT AND DEMOGRAPHIC DETAILS GP name GP phone GP practice GP fax name Provider GP address number This person has been my patient since Relationship and/or This person has been a patient at this practice since Was patient involved in discussion with GP about treatment plan? Yes No Was parent/guardian involved in discussion with GP about patient’s Yes No treatment plan? Was the parent considered for a mental health treatment plan? Yes No Patient Date of birth surname (dd/mm/yy) Patient first Preferred name(s) name Gender Female Male Self-identified gender: Patient address Patient Preferred number: Alternative number: phone Can leave message? Yes No Can leave message? Yes No Healthcare Medicare No. Card No. Has patient consented for this Parent/guardian details Treatment Plan to be released to parents/guardians? First parent/guardian: Relationship: Phone number 1: Yes No Phone number 2: With the following restrictions:
GP MENTAL HEALTH Treatment PLAN – Version for children Notes: This form is designed for use with the following MBS items. Users should be familiar with the most recent item definitions and requirements. MBS ITEM Number: 2700 2701 2715 2717 Major headings are bold; prompts to consider lower case. Response fields can be expanded as required. Underlined items of either type are mandatory for compliance with Medicare requirements. This document is not a referral letter. A referral letter must be sent to any additional providers involved in this mental health treatment plan. CONTACT AND DEMOGRAPHIC DETAILS GP name GP phone GP practice name GP fax GP address Provider number Relationship This person has been my patient since and/or This person has been a patient at this practice since Was patient involved in discussion with GP about treatment plan? Yes No Was parent/guardian involved in discussion with GP about patient’s treatment plan? Yes No Was the parent considered for a mental health treatment plan? Yes No Patient surname Date of birth (dd/mm/yy) Patient first name(s) Preferred name Gender Female Male Self-identified gender: Patient address Patient phone Preferred number: Can leave message? Yes No Alternative number: Can leave message? Yes No Medicare No. Healthcare Card No. Parent/guardian details Has patient consented for this Treatment Plan to be released to parents/guardians? First parent/guardian: Relationship: Phone number 1: Phone number 2: Yes With the following restrictions: No
gp-mental-health-treatment-plan-template-child-adolescent.docx