Arrested for Antisocial Behaviours
CONFIDENTIAL
PERSONAL DETAILS / PROVIDER DETAILS
Name: / NHI / M/F / GP Name:
Practice Name:
Address: / Practice Stamp:
DOB:
Employment Status: / NZMC#:
Preferred Contact Ph: / Referral Date:
Is there a language difficulty? / Yes / No
Language Preferred: / Primary Diagnosis:
Kessler Score
<20 / Not appropriate for this service
>35 / Patient may be too acute for this service. Consider Secondary Mental Health services or discuss with PHO Mental Health Navigator
SAFETY AND RISK ISSUES
Ideation to Harm Others: / Yes / No / History of Anti-Social Behaviour: / Yes / No
- None Expressed
- No
- Homicidal Ideas*
- Arrested for antisocial behaviours
- Intrusive thoughts – no ideation
- Assaultative behaviour
- Thoughts to damage property*
- Damage to property
History of Risk to Self: / Yes / No /
- Domestic violence
- No
- Owns/interest in weapons
- Self-harm, eg cutting
- Poor anger management
- Suicide attempt – high lethality
- Suicide attempt – low lethality
- None expressed
- Neglect of essential self-care
- Suicidal ideas – has a plan*
- Puts self in high risk situations
- Suicidal ideas – no intent
*Patient is too acute for this service. Please refer to the appropriate Secondary Mental Health Service /
- Self-harm, eg cutting*
- High risk behaviours
Lives Alone: / Yes / Alcohol Abuse: / No / Gambling: / No / Family Hx of Suicide:
No / Binge Drinker / Occasional* / Isolated or lacks intimacy
No fixed abode / Heavy Drinker / Addiction* / *Please refer to Gamblers Anonymous to address addiction issue before referring to M2M
Drug Abuse: / No / Recent Loss: / No
Benzodiazepines* / Death of loved one
IV user* / Bankruptcy
Marijuana* / Relationship Breakup
Methamphetamine* / Loss of Job
Other illicit* / Estranged from family
Other prescription* / Sexual Abuse: / No
Childhood
If yes: ETOH/Drug brief advice given: / Adult Past
*Please refer to CADS to address drug abuse before referring to M2M / Adult Recent
Patient is likely to be eligible for ACC funding for sexual abuse counselling. Please pursue this before referring to M2M
Past Mental Health History:
(Attach notes if needed) / Long Term Medication: / Long Term Conditions:
Clinical Summary/Reason for Referral:
REFERRAL TO:
PHO Navigator / “Beating the Blues” / Manage by GP / PHO Psychiatric Assessment*
*Please also attach a formal referral letter
Patient consents to referral:
NB: A contact daytime telephone number is required. Please ensure patient is aware a message may be left asking them to call the PHO.
Name and signature of Referrer / Invoice to: Auckland PHOM2M Options