Patient wellbeing assessment and recovery plan – Minimal requirements	
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.
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.	
Contact and demographic details	
GP name		GP phone		
GP practice name		GP fax		
GP address		Provider number		
Patient surname		Date of birth (dd/mm/yy)	
	
Patient first name/s		Preferred name		
Gender	 Female    Male    Self-identified gender:	
Patient address		Patient phone
Can leave message?
 Yes     No		
Medicare no.		Health Care Card/Pensioner Concession Card no.		
Emergency contact person details		Patient consent for healthcare team to contact emergency contacts?	 Yes
 No	

Patient wellbeing assessment	
Reasons for presenting

Patient history
Record:
•	Relevant medical/biological information
•	Mental health/psychological information
•	Social history		
Results of mental state examination		
Risk assessment 
Note any identified risks, including risks of self-harm and harm to others

Assessment/outcome tool used and results 
(except where clinically inappropriate)
		
Provisional diagnosis of mental health disorder
		
Case formulation	
	
Setting personal recovery goals – considerations
•	The patient themselves prioritising the goal/s to focus on
•	The CHIME framework: connectedness, hope, identity, meaning and purpose, and empowerment
•	Which strengths are relevant and can be built on to pursue goal/s
•	How the person’s values, treatment and support preferences will affect the action plan
•	Breaking goals down into smaller, manageable steps and making plans for who will do what and when – informally or using the SMART (specific, meaningful, attainable, realistic, timetabled) approach
•	Supporting the person to undertake independent or joint actions rather than accepting passive actions		

Personal recovery plan	
Identified issues/problems

	Goals
Record goals made in collaboration with patient
	Treatments and interventions
•	Actions and support services to achieve patient goals
•	Actions to be taken by patient
Consider:
•	Psychological and/or pharmacological options
•	Face-to-face options
•	Internet-based options:
­	myCompass 
­	THIS WAY UP 
­	MindSpot 
­	e-couch 
­	moodgym 
­	Mental Health Online 
­	OnTrack 	Referrals
Appropriate support services
Consider:
•	referral to internet mental health programs for education and/or specific psychotherapy
­	myCompass 
­	THIS WAY UP 
­	MindSpot 
­	e-couch 
­	moodgym 
­	Mental Health Online 
­	OnTrack 	
				
Intervention/relapse prevention plan
If appropriate at this stage, note arrangements to intervene in case of relapse or crisis		
Psycho-education provided?	 Yes		 No

Plan added to the patient’s records?	 Yes		 No	
Completing the plan 

On completion of the plan, record (tick boxes below) that you 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 patient consent	
I, ___________________________________________________ [name of patient], agree to information about my health being recorded in my medical file and being shared between the GP and other healthcare providers involved in my care, as nominated above, to assist in the management of my healthcare. I understand that I must inform my GP if I wish to change the nominated people involved in my care.
I understand that as part of my care under this Mental Health Treatment Plan, I 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	
Date for review with GP
(Initial review four weeks to six months after completion of plan)

Assessment/outcome tool results on review (except where clinically inappropriate)
		
Comments – review of patient’s progress against goals, checking, reinforcing and expanding education, modification of treatment plan (if required)

		
Plan for crisis intervention and/or for relapse prevention, if appropriate and if not previously provided