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M19tNRHYVTԨրM.sѷTtUzZ~&1N{`xʆ<:&"Џu >b"bDG@P>T"9h f\+6Ӆ hTS`PـM=; MT5Uq9a(rE奅eG^5t8.>s5yp&1H>#sP)k@h30/Y-j%{:􂛣  d DV\6䊕ݿ`\?xt ""D&BHH*eܶQ~ݡxVcAYv| xل)Sw> E3g _*+r5}J}zu}}]w `ә3Mӫf]{=Y 9"+fwwk[e&R΂ & W^]9jܮ]!ٺՁpt3GV<+glhh1!B Bփ ƕ~;OK04T-#`sDCvKFJ8$(=Q6:$ʢO}`Z[b?E^+;:cƕh4<) a#VZq]ǻBځC=cO~MLR$Hkê`dA0x}0 &3h,=lV$ydH(|lzY>GFfx"ah-HV+a5k-m%J^eKdȥWc=3 L$9؆CRFLɗ\ze}$tMƖ¾@D 1Y.utv8zt9ADA@U2J  *N+gƍ][_ӯmTI矛?~kGXA%^:¢,|KI17d&}%g~঱bO>e^9w?4AHCqo\wcso,^}N;Lڇ}Cw$JɝIZmX@iS83?fFFFvq .LMRUj+EsS]'NoJCc󡣧P8>|(Ă 08/p~:::* .,,|RDn%E5 oR:bԹHbW:'ovEN %5_s~Ҥ3MؽkGcC(,)2>dcgv9tr/fNSs3>wל{P r!:F]C|'70?tgU7ѯ$왽{Ԝ=u.pC#z-"H7o^y!v)t{Gg jjx)}/<}֭[ܲ\1hѣǪmݽ*1n;kf (/MMJ_6K/ t345r-۟~cG_.5ÇON%I #bAOOrC:x`͛FA Ӧ/MZdpE+^8Q`eC1T{XBB-BPgK`C*S &ˆ`CFu dNF.ƻfw  HP.aU d.8?;I_L].$9 `7] :@^"q}`0"mj. $%s(Ței,@‚?P&"ۡ骎D@ˎM|-)lwh9c?UE@*%T\PDMu+zQY Did{ wמq~lQx 1C?*'$ TC'mEu-&) " Ǯ1× ^{Íxh^?LCRjɚچ}KYt=m޴e? d_[љ_OĩKZ[VVβwdVede_RRSzeD̬cǎWؙ_Pው]vw߃ ~qUŽpYY,x֗z͚~^?Y&UY[W_ү煣WbiKygɇj`tMͩS:\]Sֹ#Ξ=gUW57̺7mټ{{<tvu֕t&&Kkמ8qb+2%k557nv& n5ͯp6deʶ͛ X]էb"IS&M,+-lgU-͍-\&MgXhaȠ dқ~ӴS/ԉ;fAad}}}NVFFZ z L&zr3IR$M^9}Z^Nۉ n7!'+[բ$BLMMNMKLOx<OMMM2`A ^z-}*as܋/§O[b7;wѯ[܂gwMIE࣑-FǢj$ Ƞ"{wS^ϗ3 asyy볲ZZZsطaÆ?}`ܹLT1`h, zhG[;r}8jkoASӲ2ss܊P6vl ;8.96C"[lv ifvtٳg_VVd݌z!ںx}JߓQ_ۯ/^1?0e:ZLXZR{>ǹxpaŅy{w3__0უGUd'%{Y4+FWVnߺdnk>?zfΜy rr=-99'7''+WQ]mͤnUAz%Xa,40';OƆ# 7v];RRedٖYZR:rX$2sg\2i B.2(J=KhIBiAp;ƹT }<m1>J쩦b.Rdb1a B=">״qҽ,YmȦa0ȶ ':-IENDB` 6]  @@@@d@@@@@@@h@D@#@@   FHSuicide Prevention Service GP Referral Form  - September 2019 @ @@@@@l@H@$@@@#@@@@@d@@@ =iComplete this form and fax to 03 8080 8948  assessment documentation and fax to  03 9348 0750 @#@@$@H@l@@@@@ @D@h@@@GNEw0[X%GNEw9010@@wGNEw$ GNEw9010GNEwm(ExpandedFooteGNEw9010GNEwL 4 Document (*'GNEw9010  GNEw$ GNEw9010 TRPw lls Training (TRPw0010IRPXIRPU RtdXXIRPWNitro PDF Creator (Pro 11)@ 4dA4terFNIw1FNIw0010  8MRPwMRPw4010w.A +eH+?XIPw XIPw301BORPwm(RadioButtonSePRPw1010  TNFw& TNFw0010HTimes New RomanArialCalibriTahoma WingdingsSymbol Wingdings 2CambriaTimes New Roman CETimes New Roman CyrTimes New Roman GreekTimes New Roman TurTimes New Roman (Hebrew)Times New Roman (Arabic)Times New Roman BalticTimes New Roman (Vietnamese)Arial CE Arial Cyr Arial Greek Arial TurArial (Hebrew)Arial (Arabic) Arial BalticArial (Vietnamese) Calibri CE Calibri Cyr Calibri Greek Calibri TurCalibri BalticCalibri (Vietnamese) Cambria CE Cambria Cyr Cambria Greek Cambria TurCambria BalticCambria (Vietnamese)Segoe UIScript MT BoldLucida HandwritingLucida Sans TypewriterBrush Script MT Comic Sans MSCoronetForteFreestyle ScriptGaramondCentury GothicWebdings Cambria MathCambria Math CECambria Math CyrCambria Math GreekCambria Math TurCambria Math BalticCambria Math (Vietnamese)Calibri (Hebrew)Calibri (Arabic) Arial NarrowArial Narrow CEArial Narrow CyrArial Narrow GreekArial Narrow TurArial Narrow Baltic Courier NewCourier New CECourier New CyrCourier New GreekCourier New TurCourier New (Hebrew)Courier New (Arabic)Courier New BalticCourier New (Vietnamese)LTSwNormalLTSw0010PRPw1010  TTSw1010ABATw2010Times New Roman@7-@&)*+.@b@w@  Date of Referral >(\B(\BCCCCReason for referral: >)C)C.D.D @b+ =i REFERRER DETAILS: >GmBGmBף^Cף^CCC>BBCC>FCFC.D.D &.@w@ @@p@  Referrer Relationship to client: >@@OCOCCC  o   FHSuicide Prevention Service>zdBzdB.D.D  @@p@ @F@  Referrer Name:> B B B BCC >AACC >CC.D.D  Referrer Organisation: >]B]BG BG BCC>AACC>CC.D.D  Address:>CCxf0Cxf0C.D.D >;C;CbCbCCC >;C;CBB.D.D >;C;CbCbCCC Telephone:>BBvBvBCC >AACC >CC.D.D  Fax: >CCחBחBCC >AACC>CC.D.D  Email: >ףCףCbCbCCC >AACC:. >̂ĈC.D.D &.@@7@F@w-- =i CLIENT DETAILS: >CCCC>FCFC.D.D @.@w@T@Your Title: ] JBO5 >zCzCCCYour First Name: ] JBO5 > QA QA@D@DYour Last Name: ] JBO5 >:C:CCCPreferred Name:   >BB@D@D @T@@,@DOB: ] JBO5>n=BBn=BB*C*CMarital Status: ]XXJJBO58NKOT NRTXEVSROI I >̂B̂BCCCountry of Birth: ] JBO5? >@@.D.D @@@S,&@T@@TPhone No. : (H) ] JBO5>n=Bn=BCC(m) ] JBO5J (H) ] JBO5>#D#DParent /Guardian name:  :(if child under age 16)>pBpBCC /@@@>JCJCNCNC>yCyCCC   >cCcC.D.D -@&@@ @ /@S Address (include postcode): >8 A8 A/@/@/D/D ,.@@@ Email: ]XXJJBO58NKOT NRTXEVSROI . >zBzBCC>CC@D@D>BB/D/D ,@@1#+$&@@@ @@%-- # Preferred contact method to organise first treatment session:  >=B=BCC  o  Phone/mobile>Q0BQ0B D D o  Email ./Preferred contact method for evaluation purposes:]XXJJBO58NKOT NRTXEVSROI . >)B)B D D  o  Phone/mobile>@RB@RB*D*D o  Email #$&/@@%@1@@@ Gender: ] JBO5 >"C"CCCDo you identify as LGBTIQA:   o  Yes>DCDC/D/D @@\@@@Do you identify as: >AABB o  Aboriginal >AANCNC o  Torres Strait Islander >AACC o  :Both Aboriginal & Torres Strait Islander >RARA@D@D o  Non Indigenous @@@\@@@Language spoken at home:>AA)C)C o  English only>dfFBdfFBCC o  Other specify: ____________ @7@@F@English Level: >`f@`f@BB o  Very well >H.BH.BNCNC o  Well >HBHBCC o  Not Well >z8Bz8BCC o  Not at all /@ @@F@@7Interpreter required: >z8Bz8B)C)C o  Yes >pBpBCC o  No >AACCIf yes, specify language required: >$C$C/D/D @M@~@@@ +/# Do you hold a Health Care Card or similar?>(\2C(\2CCC o  Yes >P AP ACC o  No>(C(C/D/D +@~@@>JCJCNCNC:If Yes, please write HCC Number and expiry date:>AACC]XXJJBO58NKOT NRTXEVSROI B >@@DD]XXJJBO58NKOT NRTXEVSROI C >BBNCNC /@@@~# Are you a National Disability Support Scheme (NDIS) participant?>)XB)XBCC o  Yes >P AP ACC o  No @+ :Have you been homeless in the previous 4 weeks?>AACCEmployment participation: >)\A)\ACCIs this person at risk of suicide?>`\B`\B/D/D -@@@~+/ o  Sleeping rough>p=ACp=ACCC o  Full Time>׫B׫BCCThoughts> B BDD o  Yes >@ A@ ADD o  No>BB/D/D  o  Short term/emergency accomm>xBxBCC o  Part-Time>pBpBCCIntent>$B$BDD o  Yes >@ A@ ADD o  No>BB/D/D  o  Not homeless>HCHCCC o  Not in the labour force>AACCPlan>BBDD o  Yes >@ A@ ADD o  No>BB/D/D /@@@ >(C(C)C)C>BBCC>AACC>dBdBCC>BBCCPrevious attempt>%B%BDD o  Yes >@ A@ ADD o  No>BB/D/D &,./@@@@ @@@ @ @M Primary Diagnosis (using DSM-IV)  Please mark all that apply (highlight the checkbox and enter "x" F x ) >pBpB.D.D @p@ @,.@@@@d@@@@@@< o  # Alcohol and Drug Use Disorders >p>Ap>ANCNC o  # Psychotic Disorders >AACC o  # Depression >HBHBCC o  # Anxiety Disorders>BB.D.D ,@ o  # Unexplained somatic disorders >xAxANCNC o  # Depressive symptoms >=JA=JACC o  # Anxiety symptoms>AACC o  # No formal diagnosis @@@@@@d@@@@@@<@)@@ @p@-- # K10 Score:      ______>iBiBBB D D # (score)    _________ # >pBpB.D.D -@@)@!  Current Medication  Please tick all that apply (highlight the checkbox and enter "x" F x ) >>C>C.D.D @@@@M! @@@@d@@@@ o  # Anxiolytics >zAzABB o  # Antidepressants >AAbCbC o  # Antipsychotics >AACC o  # Hypnotics and Sedatives>@\A@\ACC o  # Psychostimulants & nootropics @@@h@D@ @@@@@l@H@$@M@@@@ @@@@d@@@@(.,:  A ADD # @.:NB: provider must be a registered with the NORTH WESTERN MELBOURNE PRIMARY HEALTH NETWORK (NWMPHN) CAREinMIND services.> A ADD /@@@See the System of Care for CAREinMIND service and provider list ( https://nwmphn.org.au/health-systems-capacity-building/system-of-care/system-care-services # ) @x@b@ @$@H@l@@@@@ @D@h@@@@(/ >jCLIENT CONSENT  for service # >zDAzDA C C >jSharing information with the Commonwealth Department of Health : provision, and quality and>8 B8 B C C # o: Yes I consent for my personal details to be shared with the Commonwealth Department of Health for service >j evaluation purposes>ԣ|Bԣ|B C C quality and evaluation purposes. />CC C CClient Signature:>~bC~bCCCDate: ]R$.010/10/2019Date and Time >hBhB.D.D /: >jEvaluation of CAREinMIND >@A@A C C # o: # Yes I consent to being contacted by NWMPHN to invite me to participate in the evaluation of CAREinMIND >AA.D.D  >jServices (mobile or email address>5A5A C C # services. I agree that my contact details may be disclosed to the contracted evaluation provider for that purpose.>[/A[/A.D.D  / fie # lds are required)>QBQB C C Client Signature:>~bC~bCCCDate: ]R$.010/10/2019Date and Time # >hBhB.D.D /.: >jREFERRER/GP CONSENT # >BB C C o Yes, I have discussed this referral with my client>5B5BCC>bCbC.D.D ./ >CC C CReferrer/ GP Signature:>\2C\2CCCDate: ]R$.010/10/2019Date and Time >hBhB.D.D @x@b@ @$@H@l@@@@@ @D@h@@@@)*/ ] @$@H@l@@@@@ @D@h@@@@ I}  FHGLOSSARY: CAREinMIND"! Mental Health Services @@@@@h@D@ @@@@@l@H@$ @#@CAREinMIND"! prioritises referrals for individuals who live, work or study in the North Western Melbourne PHN catchment. Similarly, referrals may be prioritised for general practitioners, psychiatrists, paediatricians who practice in the catchment. @! #$@>)\A)\A@B@BCAREinMIND"! Suicide Prevention Support Service - Suicide prevention services provide a rapid and intensive response to individuals at heightened risk of suicide. Contact occurs within 24 hours of referral and the first session of care is generally provided within 72 hours of intake to the service. Note: this is not a crisis service. Available to all ages. @#h@$ @#@ I}For more information visit:  https://nwmphn.org.au/health-systems-capacity-building/careinmind ! #