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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$2sg\2i B.2(J=KhIBiAp;ƹT }<m1>J쩦b.Rdb1a B=">״qҽ,YmȦa0ȶ ':-IENDB` 6]  -@@@@d@@@@@@@h@D@#@@   FHGP (TPS and ISS) Referral Form   September 2019 =iComplete this form and fax to (03) 9348 0750. Attach a Mental Health Treatment Plan or FH @@#@@@@@d@@@@@$@H@l@@@@@  =iother comprehensive assessment documentation to allow for timely assessment of eligibility.GNEw%GNEw9010@@wGNEwhZXRGNEw9010GNEwhZXRGNEw9010GNEwerUsers.SearchR'GNEw9010 GNEwwser Progress AGNEw9010 TRPw lls Training (TRPw0010IRPXIRPU RtdXXIRPWNitro PDF Creator (Pro 11)@ 4dA4terFNIw1FNIw0010  MRPwMRPw4010w.A +eH+?XIPw XIPw301BORPw$ PRPw1010  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: See descriptor over the page >AA.D.D @b+. =i REFERRER DETAILS: >GmBGmBף^Cף^CCC>BBCC>FCFC.D.D &.@w@ @@p@  Referrer Relationship to client: >@@OCOCCC  o   =iTargeted Psychological FH>xBxB.D.D  @@p@ @F@  Referrer Name:> B B B BCC >AACC =i Support Service (TPS)  >BB.D.D  Referrer Organisation: >]B]BG BG BCC  o   =iIntensive Support Service (ISS)  >`=A`=A.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 +@~@@>MCMCNCNC:If Yes, please write HCC Number and expiry date:>AACC]XXJJBO58NKOT NRTXEVSROI B >]A]ADD]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$.015/10/2019Date and Time >hBhB.D.D /: >jEvaluation of CAREinMIND >@A@A C C # o: # Yes I consent to being contacted by NWMPHN to invite me to participate in the evaluation of CAREinMIND >AA.D.D  >jServices (mobile or email address>5A5A C C # services. I agree that my contact details may be disclosed to the contracted evaluation provider for that purpose.>[/A[/A.D.D  / fie # lds are required)>QBQB C C Client Signature:>~bC~bCCCDate: ]R$.015/10/2019Date 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$.015/10/2019Date and Time >hBhB.D.D )*/@x@b@ @$@H@l@@@@@ @D@h@@@@ ] @$@H@l@@@@@ @D@h@@@@ I} @@@@@h@D@ @@@@@l@H@$ FHGLOSSARY: CAREinMIND"! Mental Health Services  #! 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. ! @@# @! #$@>)\A)\A@B@BCAREinMIND"! Targeted Psychological Support Service  (formerly known as ATAPS). Short-term focused psychological interventions, for all ages. Includes up to 12 sessions of counselling support with a CAREinMIND contracted mental health clinician. @$@H@l@@@@@ @D@h@@@@>)\A)\A@B@BCAREinMIND"! Intensive Support Service  Comprehensive coordinated support for people with complex mental illness and ongoing primary support needs. Delivered by credentialed mental health nurses working in collaboration with the client s general practitioner and/or psychiatrist and other services involved in the client s care. @$@H@l@@@@@ @D@h@@@@ @$@H@l@@@@@ @D@h@@@@>)\A)\A@B@BCAREinMIND"! Wellbeing Support Service - Ideal for people who do not meet diagnosis for mental illness but are struggling with the pressures and stresses of everyday life. Phone or web-based support 24 hours per day, 7 days. Consumer information:  careinmind.com.au or counselling support line 1300 096 269  I} @@@@h@D@ @@@@@l@H@$@#h$ @#@ I}For more information visit:  https://nwmphn.org.au/health-systems-capacity-building/careinmind @#h@ I} ! # $@@$@H@l@@@@@ @D@h@@@#!  ! #$@@$@H@l@@@@@ @D@h@@@ ] ! # }Client Information #+%@@- to be handed to the client for their reference -%#.*)!  ! .You have been referred to CAREinMIND for mental health support services. There is no cost associated with this service. ! !  ! }What happens next? @1#$@@$@!  1.>)\A)\ABBA CAREinMIND counsellor will contact you, on the number you have provided, to set up an >AADD>@B@B(D(D> A ABBappointment. @. @.2.>)\A)\ABBYou and your counsellor will arrange other appointments as you need them. @. @.@H@l@@@@@ @D@h@@@@3.>)\A)\ABBBefore your first appointment: >AABBIf you have signed the consent for evaluation box you will be contacted by text or email with a link > A ABBto a You Said& survey. Please complete this survey before your first appointment. @@@@@h@D@ @@@@@l@H@.$#@1 ! !  @$@@.@!  What is You Said..? !  You Said&  is a online survey tool, used to collect and measure your experience and outcomes. You Said&  gives you a way to share your experiences of the care you receive, so that we can improve services for everyone in our community through your feedback.   How does it work?  You will be asked to complete one short survey before your first session, and two longer surveys during your treatment  at around three months and nine months. The information you share through You Said&  will help us to improve our health services and for you and others. To protect your privacy and confidentiality all information you share through You Said&  is de-identified, unless you choose to give consent for CAREinMIND staff to contact you.  }Questions?  Your GP can tell you more and get you started with You Said&  It s great to have you on board! Or visit www.nwmphn.org.au/yousaid /@ ! @)*/#%- @@