Patient wellbeing assessment and recovery plan – Adults	
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		
Relationship	This person has been my patient since		
	and/or	
	This person has been a patient at this practice since		
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/Pension No.		
Highest level of education completed	 Primary school
 Secondary school
 TAFE
 Tertiary degree
Comments:

Is this person a parent of a child aged <18 years?   Yes    No
		
Carer/support person contact details	Has patient consented for this healthcare team to contact carer/support persons?	
First contact:	Relationship:	Phone number 1:

Phone number 2:

	 Yes

With the following restrictions:
	 No	
Second contact:	Relationship:	Phone number 1:

Phone number 2:
	 Yes

With the following restrictions:
	 No	
Emergency contact person details	Has patient consented for this 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	
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 factors		

Patient wellbeing and 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:
•	Symptom onset, duration, intensity, time course		
Patient history
Consider:		
•	Mental health history 		
•	Salient social history		
•	Salient medical/biological history 
Consider asking:
♀ – menarche, menstruation, pregnancy, menopause		
•	Salient developmental issues		
Family history of mental illness
Consider asking about:
•	Family history of suicidal behaviour
•	Genogram		

Parent and children needs
Record:
•	Name and date of birth of any children aged ˂18 years.  
•	Impact of mental health difficulties on their parenting, the parent–child relationship and their children		
Current domestic and social circumstances
Consider asking about:
•	Living arrangements
•	Social relationships
•	Occupation		
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:
•	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; Family Care 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 asking about:
•	Appearance, cognition, thought process, thought content, attention, memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation
•	Appropriateness of Mini-Mental State Examination (MMSE) for patients aged ˃75 years or if otherwise indicated	
	
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		
Consider possible indicators of gender-based violence-related trauma
Possible indicators may include:
•	Stress, anxiety, depression
•	Substance use disorders
•	Thoughts, plans or acts of self-harm/suicide
•	Injuries that are repeated and unexplained
•	Repeated sexually transmitted infections
•	Unwanted pregnancies
•	Unexplained chronic pain or conditions (pelvic pain, gastrointestinal problems, kidney or bladder infections) 
•	Other unexplained mental health complaints
		
Risk assessment 
If high level of risk indicated, document actions taken in the 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)		
Date of assessment		
Results

 Copy of completed tool provided to referred practitioner	
Provisional diagnosis of mental health disorder
Consider conditions specified in the International classification of primary care, 2nd edition:
•	Depression
•	Bipolar disorder
•	Other mood disorders
•	Anxiety disorders
•	Panic disorder
•	Phobic disorders
•	Post-traumatic stress disorder
•	Schizophrenia
•	Other psychotic disorders
•	Adjustment disorder
•	Dissociative disorders
•	Eating disorders
•	Impulse-control disorders
•	Sexual disorders
•	Sleep disorders
•	Somatoform disorders
•	Substance-related disorders
•	Personality disorders
•	Unknown		
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
•	Content from individuals other than the patient		
Any other comments		
Record of patient consent for personal recovery plan	

I, ___________________________________________________ [name of patient], agree to complete the recovery plan.

Considering the recovery journey – Optional frameworks, stages and tasks to consider	
Stage of personal recovery	

1. Feeling overwhelmed 	
2. Acknowledging change is needed	
3. Actively struggling with mental health	
4. Living with impact of illness or vulnerability 	
5. Living beyond illness or vulnerability 	

Notes informed by stages 1–5 above; consider small, comprehensible and achievable steps	

	

Recovery task 1 – Understanding my mental health, and what it means for me	

Has confusion about what happened and what it means	
Is aware that something needs to be understood or sorted out 	
Has a beginning explanatory model of causal attributions	
Has come to terms with mental health and what it means to them	
Is comfortable with own personal understanding of experiences	

Notes informed by dimensions of task 1: consider small, comprehensible and achievable steps	

	

Recovery task 2 – Taking charge of my mental health	

Is not making a deliberate effort to cope	
Realises the need to cope or change	
Is sometimes trying ways to cope or change	
Is generally confident in managing persisting illness or vulnerability	
Mental health experiences interfere little with life	

Notes informed by dimensions of task 2: consider small,  comprehensible and achievable steps	

	

Recovery task 3 – Living a life that I value	

Feels disconnected from people, social roles and personal growth	
Would like to be more connected to people, social roles and personal growth
 	
Is sometimes trying ways to connect and change	
Has found a place in life but still limited by disabilities	
Has a ‘contributing life’	

Notes informed by dimensions of task 3: consider small, comprehensible and achievable steps	

	
Setting personal recovery goals	
Also consider:
•	The person 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 impact on 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	
		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 for what
•	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
•	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	

  Preparation of plan for delegation of patient’s responsibilities (e.g. care for dependants, pets)	
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 (e.g. 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 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	
________/________/________
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