Suicide Prevention Service - Referral Form printable pdf download

Suicide Prevention Service - Referral Form

Suicide Prevention Service – Referral Form

Fax to: 8822 8560

Patient Details

First name:_______________________________

Surname: :_______________________________

Gender:

Male

Female

Date of Birth:_____/_____/_____

Language spoken:_________________________

Interpreter needed? Yes/No

Phone number:___________________________

Email:___________________________________

Address:________________________________

Postcode:________________________________

Patient key contact / support person/s name and phone number:

______________________________________________________________________________________

General Practitioner Details

GP name:____________________________________ Practice:__________________________________

Practice address:______________________________ GP email:_________________________________

Phone no:____________________________________ Practice fax:_______________________________

Suicide Risk Assessment – see supporting suicide risk assessment guide

I have assessed the patient to BE AT LOW TO MODERATE RISK of suicide.

Consent

I have provided the patient with the Suicide Prevention Service Information sheet.

The client has verbally consented to be contacted by the Suicide Prevention Service clinician.

Please give a brief description of the reason for referral and any contextual information you think will be

helpful.

Pre-existing Diagnosis:

Current Medications:

After Hours Support

–

For referrals made after 3.30 pm (Mon-Thurs), Friday, Saturday, Sunday & public holidays.

Phone ATAPS After Hours Suicide Support Line 1800 859 585 to book a call back for support until the

Suicide Prevention Service can contact the client.

ATAPS After Hours Suicide Support line information sheet

and then

Fax referral to Suicide Prevention Service 8822 8560

GP signature:____________________________________

Date:_____/_____/_____

Suicide Prevention Service - Referral Form