Form 1 - Brisbane MIND Approved Clinician Referral for Additional Sessions Patient Details Patient Name DOB: GP is not available to complete review due to leave or other circumstances Original referral was not completed by a GP Reason patient is not Patient is in the process of changing GPs returning to GP for a Patient has seen their usual GP within the past two weeks and discussed progress in the review Brisbane MIND program Other (please describe): Patient has completed 6 sessions under general Brisbane MIND and requires an additional 6 sessions Referral Situation Patient has completed sessions under the Brisbane MIND Suicide Prevention Program and is able to transition to general Brisbane MIND Treating Approved Clinician Approved Clinician Name GP Details GP Name General Practice Referral Date GP or other referrer has Yes been advised of this referral Indicated level of 1. Absent (General Program) Suicide risk: 2. Mild (General Program) 3. Moderate (Suicide Prevention Program) 4. High (Suicide Prevention Program) 5. Acute (Acute Care Team or Ambulance)
Form 1 - Brisbane MIND Approved Clinician Referral for Additional Sessions Patient Details Patient Name DOB: Reason patient is not returning to GP for a review GP is not available to complete review due to leave or other circumstances Original referral was not completed by a GP Patient is in the process of changing GPs Patient has seen their usual GP within the past two weeks and discussed progress in the Brisbane MIND program Other (please describe): Referral Situation Patient has completed 6 sessions under general Brisbane MIND and requires an additional 6 sessions Patient has completed sessions under the Brisbane MIND Suicide Prevention Program and is able to transition to general Brisbane MIND Treating Approved Clinician Approved Clinician Name GP Details GP Name General Practice Referral Date GP or other referrer has been advised of this referral Yes Indicated level of Suicide risk: 1. Absent (General Program) 2. Mild (General Program) 3. Moderate (Suicide Prevention Program) 4. High (Suicide Prevention Program) 5. Acute (Acute Care Team or Ambulance)
FORM%201%20-%20Approved%20Clinician%20Referral%20for%20Additional%20Sessions.docx