headspace Armadale is a free, youth-friendly, confidential services available to young people aged 12 – 25 years, in the South East metropolitan region of Perth. The mental health services are for mild to moderate (tier 1 and 2) presentations. headspace Armadale brings together a range of co-located community-based and government agencies, to provide a holistic service as a “one-stop-shop” for young people. We offer information, intake, assessment and referral.
Services available at headspace Armadale include:
•	Mental health and emotional support
•	MBS Psychological service
•	MBS Mental Health Social Work service
•	Counselling
	•	Drug and alcohol support
•	Work and study support
•	Sexual health clinic

GP Mental Health Treatment Plan MBS item numbers 2715/2717 or 2700/2701
	
GP MENTAL HEALTH TREATMENT PLAN – PATIENT ASSESSMENT	
Patient’s Name	     
	Date of Birth	     	
Address	     
	Phone	     	
Carer details and/or emergency contact	     
	Medicare Number 
Issue Number
Expiry Date	     
     
     
	
Patient consent 
Patient has agreed to GP Mental Health Care Plan Service	
 Yes    No	
GP Name/Practice
Provider Number	     

     	
PRESENTING ISSUE(S)
What are the patient’s current mental health issues	     	
PATIENT HISTORY
Relevant biological, psychological, physical
social history including family history of mental disorders and any relevant substance abuse 	     	
MEDICATIONS
(attach information if required)	Is the patient receiving psychotropic medication?   Yes    No If yes, please specify below
 Benzodiazepines & Anxiolytics                           Antidepressants      
 Phenothiazines & Tranquilisers                          Mood Stabilisers      
Other      
	
ALLERGIES	     	
OTHER RELEVANT INFORMATION	     

Are there any legal proceedings pending? (please note headspace is unable to provide opinion re: legal matters or supporting documents)  No        Yes If yes, please specify
     	

RESULTS OF MENTAL STATE EXAMINATION
Record  	Appearance 
Cognition 
Thought Process 
Thought Content 
Attention 
Memory 
Insight 	     
     
     
     
     
     
     	Behaviour 
Speech 
Mood 
Affect
Perception
Judgement 
Orientation	     
     
     
     
     
     
     	
RISKS ASSESSMENT
Note any identified risks, including risks of self-harm and harm to others, ideation/thoughts, intent or plans
	     	
OUTCOME TOOL USED
E.g. K10, DASS-21
(except where clinically inappropriate or culturally unsafe)	RESULTS (please attach)
     	
DIAGNOSIS	     	

GP MENTAL HEALTH TREATMENT PLAN – PATIENT PLAN	
PATIENT NEEDS/MAIN ISSUES
	GOALS - record the mental health goals agreed to by the patient and GP and any actions the patient will need to take
	TREATMENTS
Treatments, actions and support services to achieve patient goals
	REFERRALS
Note: Support services or local groups that are culturally appropriate. Can provide up to six sessions then review for an additional four sessions.	
     
	     
	Referred for which strategies:
 Diagnostic assessment
 Psycho-education
 Interpersonal therapy
Cognitive-behavioural therapy (CBT):
 Cognitive interventions
 Relaxation strategies 
 Skills training 
 Other CBT interventions (please specify)      
Other (please specify)      
	     
	
CRISIS/RELAPSE
If required, note the arrangements for crisis intervention and/or relapse prevention.	     	
PSYCHO-EDUCATION PROVIDED
 Yes    No	PLAN ADDED TO THE PATIENT’S RECORDS
 Yes    No	COPY (OR PARTS) OF THE PLAN OFFERED TO OTHER PROVIDERS
 Yes    No	
COMPLETING THE PLAN 
On completion of the plan, the GP is to record that they have discussed with the patient:
 The assessment             
 All aspects of the plan, including referrals to other providers
 Agreed date for review                 
 Offered a copy of the plan to the patient and/or their carer (if agreed by patient)	DATE MENTAL HEALTH TREATMENT PLAN COMPLETED
     	
	REVIEW DATE (initial review 4 weeks to 6 months after completion of plan)
     	

Email the Mental Health Care Plan and referral form or cover letter to referrals@headspacearmadale.com.au or fax to 08 9393 0399