Step Thru Care & Multi Disciplinary Team Referral Form

Step Thru Care (STC) is available to support people with low level needs, to mild and severe mental healthissues and/or alcohol and other drugs support needs. In particular, the program is available to people in thefollowing priority groups within the Great South Coast catchment.

Criteria:

People with low income (e.g. health carecard holders)
People from cultural and linguistically diverse(CALD) backgrounds
People experiencing perinatal depression
Children under the age of 12 years
People in areas impacted by naturaldisaster (e.g. drought)
People experiencing short-term displacementor homelessness
People who live in rural or remote areas
People not in receipt of a NDIS plan
People who identify as Aboriginal and/orTorres Strait Islander
People experiencing or at risk of domesticviolence
People who identify as LGBTIQA+

The Mental Health Multi-Disciplinary Team (MH-MDT) Program delivers integrated, coordinated care forpeople living with severe and/or complex mental health needs in the Great South Coast catchment.

Criteria for those who:

Have severe and/or complex mental health needs
Experience episodic or persistent mental illness
Are significantly impacted in their day-to-day lives
May be experiencing social or environmental stressors related to their mental health

Receiving STC & MH-MDT service should not be duplicative of other mental health services being provided.People aged 12–25 should be referred to Headspace in the first instance. Please include any supportingdocumentation if available, including mental health assessments/ psychiatric review. STC and MH-MDT arenot crisis services, please refer to Southwest Healthcare if acute risk is present 1800 808 284.

How to Refer

Referrals can be made via one of the following options

Mind Connect Self-Referral
1300 286 463
GP and Formal Supports to email referral form to:
rcpgsc@mindaustralia.org.au
Complete and submit this form

Step Thru Care & Multi Disciplinary Team Referral Form (Page 2)

Consumer Details

If you don't have or know this information, you can enter NA, or None, or I don't know.

First Name *

Last Name *

Date of Birth *

Gender *

Pronouns *

Fixed Address *

Fixed address - please provide belowNo fixed address currently

Address *

Street address *

City *

State *

Postcode *

If you don't have or know this information, you can enter NA, or None, or I don't know.

Place of Birth *

Main Language Spoken *

Indigenous status *

Source of Income *

Step Thru Care & Multi Disciplinary Team Referral Form (Page 3)

Supports and GP Details

If you don't have or know this information, you can enter NA, or None, or I don't know.

Emergency Contact *

Current Mental Health Supports *

YesNo

Details *

GP Name / Clinic *

GP Contact Details *

Referrer Details

If you don't have or know the Referrer's name or organisation, you can enter NA, or None, or I don't know.

Referrer Name *

Organisation *

If you don't have or know the Referrer's phone number or email, please skip these questions.

Phone Number

Clinical Information

If you don't have or know this information, you can enter NA, or None, or I don't know

Principal Diagnosis *

Additional Diagnoses *

Main Substance *

Other Substance *

Quantity / Frequency *

Legal / Corrections / Child Protection / IVO *

Medication Details *

Risk Summary

If you don't have or know this information, you can enter NA, or None, or I don't know

Current suicidal ideation *

YesNo

Details *

Recent Suicide Attempt *

YesNo

Details *

Self-harm concerns *

YesNo

Details *

Violence / aggression risk *

YesNo

Details *

Child safety concerns *

YesNo

Details *

Other urgent risks *

YesNo

Details *

Reason for Referral *

Goal for seeking Mental Health Support *

Supporting Documentation

Please upload your Mental Health Care Plan, and/or other supporting documents below.

If you do not have any supporting documents, please skip this question.

File Upload

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