Patient wellbeing assessment and recovery plan – Children and adolescents 	
Notes: This form is designed for use with the following Medicare Benefits Schedule (MBS) items. Users should be familiar with the most recent item definitions and requirements.
MBS item number:    2700     2701     2715     2717    
This document is not a referral letter. A referral letter must be sent to any additional providers involved in this Mental Health Treatment Plan.
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	
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.		Health Care 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	
Second parent/guardian:	Relationship:	Phone number 1:

Phone number 2:
	 Yes

With the following restrictions:
	 No	
Emergency contact person details	Patient/parent/guardian consent for healthcare team to contact emergency contacts?	
First contact:	Relationship:	Phone number 1:

Phone number 2:
	 Yes	 No	
Second contact:	Relationship:	Phone number 1:

Phone number 2:
	 Yes	 No	
Schooling (if applicable)	
Current school level		Name of school/preschool		
Salient school factors
Consider asking:
•	Has there been any prior disruption to schooling?
•	What is the current frequency of school attendance?
•	What is the patient’s ability to start and finish homework?
•	How are the patient’s peer relationships?
•	Has the patient experienced any bullying?
•	Has the patient experienced any traumatic school community events?
		
Patient/guardian consent to discuss GPMHTP with the following members of school community:	
	Role	Name/s	Phone	
 Yes	Principal			
 Yes	Assistant Principal/s			
 Yes	Teacher/s			
 Yes	School counsellor/s			
 Yes	Other			
Salient communication and cultural factors	
Language spoken at home	 English	 Other:	
Interpreter required	 No	 Yes, comments:	
Country of birth	 Australia	 Other:	
Other communication factors		
Other relevant cultural issues		

Patient wellbeing assessment	
Reasons for presenting
Consider asking:
•	What are the patient’s current mental health issues?
•	What requests and hopes does the patient have?
		
History of current episode
Consider asking about:
•	Symptom onset, duration, intensity, time course 
		
Implications of symptoms on child/adolescent’s daily activities
		
Patient history
Consider:		
•	Mental health history
		
•	Salient social history
		
•	Salient medical/biological history
•	♀  – menarche, menstruation, pregnancy
		
Salient developmental issues		
Family history of mental illness
Consider asking about:
•	Family history of suicidal behaviour
•	Genogram
		
Current domestic and social circumstances
Consider asking about:
•	Living arrangements
•	Siblings
•	Custodial arrangements
•	Social relationships
Engagement with peers
		
Salient substance use issues
Consider asking about:
•	Nicotine use
•	Alcohol use
•	Illicit substances
•	Is patient willing to address the issues?		
Current medications
Consider asking about:
•	Dosage, date of commencement, date of change in dosage
•	Reason for the prescription 
•	Are there other practitioners involved in the prescription of medication?
•	Are there issues with compliance or misuse?		
History of medication and other treatments for mental illness
Consider asking about:
•	School counselling and other school interventions
•	Past referrals
•	Effectiveness of previous treatments
•	Side effects and complications associated with previous treatments
•	Patient’s preference for medications
		
Allergies
		
Relevant physical examination and other investigations		
Results of relevant previous psychological and developmental testing		
Other care plan
E.g.  GP Management Plans and Team Care Arrangements; 
Wellness Recovery Action Plan	 Yes, specify:  
 
 No   

Comments on strengths and positive dispositions	
Consider asking about:
•	Abilities, talents and interests
•	Competencies and accomplishments 
•	Previous self-help strategies used and those available in the family support network 
•	Service system and the community at large
		
Comments on current mental state examination	
Consider:
•	Appearance, cognition, thought process, thought content, attention, memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation

	
Trauma-informed care and practice (TICP) assessment	
Consider possible influence of trauma
Trauma can be defined as:
•	Exposure to death
•	Threatened death
•	Actual serious injury 
•	Threatened serious injury
•	Actual sexual violence 
Threatened sexual violence		
Risk assessment – 
If high level of risk indicated, document actions taken in treatment plan below 

Consider asking:
•	Does the patient have a timeline for acting on a plan?
•	How bad is the pain/distress experienced?
•	Is it interminable, inescapable, intolerable?		Ideation/thoughts	Intent	Plan	
	Suicide	
			
	Self-harm	
			
	Harm to others	
			
	Comments or details of any identified risks	
		
Assessment/outcome tool used, 
(except where clinically inappropriate)
•	e.g., Strengths and Difficulties Questionnaire
•	Note: K-10 is not validated for minors

	
Date of assessment
		
Results

 Copy of completed tool provided to referred practitioner	
Provisional diagnosis of mental health disorder
Consider conditions specified in the ICPC, including:
•	Anxiety co-morbid with autism
•	ADD/ADHD
•	Conduct disorder
•	Oppositional defiant disorder
•	Mood disorder
•	Separation anxiety
•	Phobias
•	Elective mutism
•	Reactive attachment disorder
•	Nonorganic enuresis and encopresis
•	Eating disorder
•	Adjustment disorder (eg grief/loss/ parental separation/trauma/medical condition)
•	Depression
•	Anxiety
•	Unexplained somatic disorder
•	Mental disorder not otherwise specified		
Case formulation
Consider asking about:
•	Predisposing factors
•	Precipitating factors
•	Perpetuating factors
•	Protective factors 		
Other relevant information from carer/informants
Consider asking about:
•	Specific concerns of carer/family
•	Impact on carer/family
•	Contextual information from members of patient’s community
•	Other content from individuals other than the patient
		
Any other comments		

Personal recovery plan	
		Actions	
Identified issues/problems
Consider:
•	As presented by patient
•	Developed during consultation
•	Formulated by GP
	Goals
Consider:
•	Goals made in collaboration with patient
•	What does the patient want to see as an outcome from this plan?
•	Wellbeing, function, occupation, relationships
•	Any reference to special outcome measures
•	Time frame	Treatments & interventions
Consider:
•	Suggested psychological interventions
•	Medications
•	Key actions to be taken by patient 
•	Support services to achieve patient goals
•	Role of GP
•	Psycho-education
•	Time frame
•	Internet-based options: 
­	myCompass 
­	THIS WAY UP 
­	MindSpot 
­	e-couch 
­	moodgym 
­	Mental Health Online 
­	OnTrack
	Referrals
Consider:
•	Practitioner, service or agency – referred to whom and what for
•	Specific referral request
•	Opinion, planning, treatment
•	Case conferences
•	Time frame
•	Referral to internet mental health programs for education:
­	myCompass 
­	THIS WAY UP 
­	MindSpot 
­	e-couch 
­	moodgym 
­	Mental Health Online 
­	OnTrack
	Any role of carer/support person(s)
Consider:
•	Identified role or task/s (eg monitoring, intervention, support)
•	Discussed, agreed, and negotiated with carer?
•	Any necessary supports for carer
•	Time frame	
Issue 1:	

	
	
Issue 2:	

	
	
Issue 3:	

	
	
Intervention/relapse prevention plan (if appropriate at this stage)
Consider asking about:
•	Warning signs from past experiences
•	Arrangements to intervene in case of relapse or crisis
•	Support services currently in place
•	Any past effective strategies

Psycho-education provided if not already addressed in ‘Treatments and interventions’ above?
	 Yes		 No
	
Plan added to the patient’s records?	 Yes		 No	

Other healthcare providers and service providers involved in patient’s care
(eg psychologist, psychiatrist, social worker, occupational therapist, other GPs, other medical specialists, case worker, community mental health services)	
Role	Name	Address	Phone	

Completing the plan  
	
On completion of the plan, the GP may record (tick boxes below) that they have:

  Discussed the assessment with the patient
  Discussed all aspects of the plan and the agreed date for review
  Offered a copy of the plan to the patient and/or their carer (if agreed by patient)
	 Date plan completed	

Record of consent	
I, ___________________________________________________[name of patient or parent/guardian as applicable], agree to information about my/my charge’s health being recorded in my medical file and being shared between the GP and other healthcare providers involved in my/his/her care, as nominated above, to assist in the management of my/my charge’s healthcare. I understand that I must inform my GP if I wish to change the nominated people involved in my/my charge’s care.  
I understand that as part of my/my charge’s care under this Mental Health Treatment Plan, I/he/she should attend the general practice for a review appointment at least four weeks, but no later than six months, after the plan has been developed.
I consent to the release of the following information to the following carer/support and emergency contact persons.	
Name	Assessment	Treatment plan	
	Yes	No	Yes	No	
	 With the following limitations:
	
	 With the following limitations:

	 With the following limitations:
	
	 With the following limitations:

__________________________________________
Signature of patient or guardian	
________/________/________
Date	

I, ________________________________________, have discussed the plan and referral/s with the patient.
Full name of GP	
Mental Health Treatment Plan included:                                                          

__________________________________________
Signature of GP	      No          Yes (if yes, please select below)
                        MBS item number:  
                         2700     2701     2715   2717    
________/________/________
Date	
Request for services

Date: 

To:
[Attn]
[Address]
[Post code]

Subject: Letter of request for services

Dear Dr

I am referring [patient’s name] for 

I am referring [patient’s name] [date of birth] for [number of sessions] sessions.

I have been [patient’s name]’s primary care physician for the past [number of years] years.

In summary, the following assessment and treatment planning has been undertaken: [  ]

Mental Health Treatment Plan attached:  Yes  No

Specific treatment requests: [  ]

If you have any questions, please feel free to contact me directly. I will be available on phone [T+00000000] and email [email@email.com] in case of any query.

Looking forward to your reply.

Yours sincerely,

[Signature]
				
[Physician’s name and title]

[Provider number]

	

Review	
MBS item number:    2712     2719	
Planned date for review with GP
(Initial review four weeks to six months after completion of plan)		
Actual date of review with GP 	
	
Assessment/outcome tool results on review
(except where clinically inappropriate)

Comments 
Consider:
•	Progress on goals and actions
•	Identified actions have been initiated and followed through (e.g. referrals, appointments, attendance)
•	Checking, reinforcing and expanding education
•	Communication between the GP and patient
•	Where appropriate, communication received from referred practitioners
•	Modification of treatment plan if required
		
Intervention/relapse prevention plan (if appropriate)
Consider:
•	Warning signs from past experiences
•	Arrangements to intervene in case of relapse or crisis
•	Other support services currently in place
•	Any past effective strategies