Ph: 1800 223 365 – Psychological Therapy Services (PTS) dedicated referral line 
No PTS sessions can be provided without a referral code.

Attach this referral letter to the Mental Health Treatment Plan/Review and send to the PTS AHP.
Date of Referral	Patient Initials	Year of Birth	M/F	Patient Post Code	PTS REFERRAL CODE	
<<Miscellaneous:Date>>		<<Patient Demographics:DOB>>	<<Patient Demographics:Gender>>	<<Patient Demographics:Postcode>>		

PTS Provider Name        <<Addressee:Name>>	
Attached, please find an assessment for a patient that I wish to refer to you under the Nepean Blue Mountains PHN Psychological Therapy Program for Focussed Psychological Strategies (FPS).

      Eligibility
•	I have completed a Mental Health Treatment Plan/Review for this patient and refer for:
     (MHTP is not required for Bushfire PTS Referrals)	
PTS General (Health Care Card/Pension Card required) – 
eligibility definitions available below patient consent.	PTS Child Services
(Family HCC required)	
•	Bushfire (No HCC required)	•	Children 	
•	Carer of a person with disability, medical condition, mental illness or frail and aged		
•	 Young people aged 12-25 years who reside in the Blue Mountains or Hawkesbury LGA
•	 Perinatal
•	 Aboriginal or Torres Strait Islander (No HCC required)
•	 Lesbian, Gay, Bisexual, Transgender, Queer, Intersex (LGBTQI)	   PTS Extended (HCC 
   required)  
•	Over 25 years of age, with complex trauma	
•	 Co-Morbid Alcohol and Other Drug (AOD)		

This referral is valid for 2 months and expires on:          	
The first PTS session must occur on or before the expiry date

This patient needs to return to me for a review by:        								The review with the GP has to occur within 6 months of the referral date

Diagnosis (please select all applicable)
•	Depression	•	Anxiety disorder	•	Alcohol/ drug use disorder	
•	Psychotic disorder	•	Unexplained somatic disorder	•	   PTSD or disclosed complex trauma	

GP Stamp

If Other (specify):   							 
Please do not hesitate to contact me if you have any questions or concerns

GP signature:
(Provide GP details or stamp)

Patient consent:
I give consent for information about my mental health and wellbeing to be collected, used and disclosed between my GP and mental health   provider to whom I am referred, where this is required to assist in the management of my health care; and; I am aware that my name and date of birth will be collected and securely stored by the Nepean Blue Mountains PHN, for the purpose of accurately tracking referrals; and  I am also aware that information (that will not identify me to any external parties) is being collected and used to assist in improving the regional Psychological Therapy Services (PTS) program. I understand de-identified information pertaining to services accessed will be recorded in the secure Primary Mental Health Care, Minimum Data Set (Australian Government, Department of Health) and that information handling and storage will be in adherence to the Australian Government Privacy Act, 1988. 

Patient Signature:   			                	             Date:   <<Miscellaneous:Date>> 

Referral eligibility criteria: 

General Service tiers: (five sessions per referral, and eligible for one re-referral)
•	Aboriginal and Torres Strait Islanders – individuals whom identify as Aboriginal or Torres Strait Islander and require access to psychological therapy (No Healthcare or Pension Card required).
•	Perinatal – women whom are pregnant, or have had a child within the past 12 months and require access to psychological therapy (Healthcare, Pension or Family HCC required).
•	Alcohol & Other Drugs - requires a person to have a co-existing substance use and mental health issue, both of which are clinically and/or socially significant.  Please note: the person engaging in therapy sessions must not be under the influence of AOD (Healthcare or Pension card required).
•	Carers - people who provide personal care, support and assistance to another individual due to disability, medical condition (including terminal or chronic illness), mental illness or are frail and aged. A person is not eligible if they provide care for payment, as a volunteer for an organisation, or as part of the requirements of a course of education or training (Healthcare or Pension card required).
•	Lesbian, Gay, Bisexual, Transgender, Queer and Intersex (LGBTQI) people – individuals whom identify as LGBTQI, or have concerns related to their experience of sexuality or gender (Healthcare or Pension card required).
•	Young People aged 12 – 25 years whom reside in the Blue Mountains or Hawkesbury LGA - (Healthcare, Pension or Family HCC required).

Child Psychological Services: (five sessions per referral, and eligible for one re-referral)
•	Children under 12 years of age, who have or are at risk of developing a mild to moderate mental health, behavioural or emotional disorder and are likely to benefit from short term intervention (Family HCC or Pension card required).

Extended/Longer term Therapy Services (25 hours per referral, spanning twelve months from referral date. Individuals are eligible for one re-referral after the twelve months has expired, and requires a further 25 hours)
•	Individuals living with moderate to severe mental illness with added complexity e.g. trauma, and people with severe or complex presentations that do not require substantial clinical care coordination.
•	Must be over 25 years of age and possess a HCC or Pension card. 

Seek Out Support (SOS) Services: (Unlimited sessions within a 2 month period, re-referrals accepted) – please refer to SOS patient referral form. 
•	Individuals with a low to moderate risk of suicide requiring intensive psychological support. 
•	Must be 14 and over to access services (No Healthcare or Pension card required). 
•	Family or friends considered at risk in the aftermath of a suicide are also eligible to be referred. 

Bushfire: (10 sessions until 2021) The Bushfire PTS stream is available to anyone in our region experiencing high levels of distress resulting from recent bushfires. For example, people who have experienced loss of property, loss of business income, or have experienced significant mental health impacts as a result of the threat of bushfire, which could be from past trauma.
•	No Healthcare or Pension card required
•	No Mental Health Care Plan is required, however GP may complete one at their discretion. 
•	Where appropriate, couples or family members who meet the eligibility criteria may be referred and seen together rather than individually.