ATAPS Referral Form - WentWest

ATAPS Referral Form
Thank you for referring your patient into the WentWest ATAPS Program.
Please complete the following details and fax to the WentWest Confidential Fax line: (02) 8208 9941
Once received, a purchase order will be sent to the Allied Health Professional (AHP) authorising
patient treatment.
Yes, I have placed my patient on a recall / reminder system for the REVIEW step.
GP name
AHP name
Postcode
Referral date
Patient Name
Patient Year of Birth
Referral type
Language spoken
other than English
Postcode
Gender
M F
General ATAPS Perinatal Depression Suicide Prevention
Homelessness Pre Adolescent Children Telephone CBT
Indigenous Community 2009 Victorian Bush fires
No, only English Italian Greek Cantonese
Mandarin Arabic Vietnamese
Other, please specify
English Level Very Well Well Not Well Not at all Unknown
Education level Tertiary Year 12 Year 11 year 10,9,8 Primary or below
Aboriginal or Torres
Yes (Aboriginal) Yes ( Torres Strait Islander) No Unknown
Strait Islander
Lives alone Yes No Unknown
Low income earner Yes No Unknown
Prior Mental health
care
Yes No Unknown
Outcome Tool
Is this patient rereferred
K 10
Edinburgh Depression Scale
Other
Yes
ICD-10 Primary Diagnostic
Categories (please tick all that
apply)
F1 Alcohol and Drug Use
Disorders
F2 Psychotic Disorders
F3 Depression
F4 Anxiety Disorders
F5 Unexplained somatic disorders
Other: ____________________
Unknown
Other Comments
No of Sessions requested
No, this is the first referral
Referred for which strategies (please
tick all that apply)
Diagnostic Assessment
Psycho-Education
Cognitive Intervention (CBT)
Behavioural Intervention (CBT)
Relaxation Strategies (CBT)
Skills Training (CBT)
Interpersonal Therapy
Other CBT intervention: ___________
Score Pre-Treatment
Score Post-Treatment
Receiving Psychotropic
Medication (please tick
all that apply)
None
Benzodiazepines &
Anxiolytics
Anti-Depressants
Phenothiazines &
Tranquilisers
Mood Stabilisers
1 2 3 4 5 6
For more information contact the ATAPS coordinator on 02 8811 7100 or email ataps@wentwest.com.au
Name:
I have read the Patient Information leaflet and I
give consent for my information to be shared with
Address:
Western Sydney Medicare Local.
Telephone:
Signature:______________________________
Please fax completed form to the WentWest confidential fax number (02) 8208 9941

ATAPS Referral Form
Thank you for referring your patient into the WentWest ATAPS Program.
Please complete the following details and fax to the WentWest Confidential Fax line: (02) 8208 9941
Group Sessions Section
Type of Group Anger Busters Anxiety Busters
Anxiety Management
Managing Insomnia
Depression Management
Perinatal Group Therapy
Risk of Harm to Self Suitability: Mild Moderate
Comments if any:
Risk of Harm to Others
Affects on Functioning in a Group
Setting
Clinical Information/ Reason for
Referral
Any Other Providers Involved in
Care
I have informed the patient that the triage service will contact them.
Patients contact number.
Please fax completed form to the WentWest confidential fax number (02) 8208 9941