Patient wellbeing assessment and management plan: Minimal requirements
(GP Mental Health Treatment Plan)	
Note: This form is designed for use with the following Medicare Benefits Schedule (MBS) items. Users should be familiar with the most recent item definitions and requirements.
MBS item number:   ☐2700     ☐ 2701     ☐ 2715     ☐ 2717     ☐ 281     ☐ 282
This document is not a referral letter. A referral letter must be sent to any additional providers involved with this GP Mental Health Treatment Plan.
Major headings are in bold; prompts to consider are in lower case; Underlined items of either bold or lower case are mandatory for compliance with Medicare requirements.	
Contact and demographic details	
GP name		GP phone number		
General practice name		GP fax number		
General practice address		Provider number		
Patient last name		Date of birth (dd/mm/yyyy)	
	
Patient first name/s as per Medicare card		Patient preferred name		
Pronouns	☐ She/her/hers   ☐ He/him/his   ☐ They/them/theirs   ☐ Other:	
Sex assigned at birth	☐ Male   ☐ Female  ☐ Intersex   ☐ Another term:	
Gender	☐ Female    ☐ Male     ☐ Transgender      ☐ Non-binary    ☐ Gender diverse   
☐ Different term:        ☐ Do not know        ☐ Prefer not to answer	
Patient address		Patient phone number
Can leave a message?
☐ Yes     ☐ No		
Medicare number		Health Care Card/Pensioner Concession Card number		
Emergency contact person details (Option to record more than one contact)	1.

2.

3. 
	Patient consent for healthcare team to contact emergency contacts?	☐ Yes
☐ No	
Information that cannot be shared with emergency contacts and/or carers		
Carer/next of kin name, phone number and email address
Record:
•	Who else can the healthcare team contact to discuss care of the patient?
•	Who else is involved in making decisions for the patient?
		
Preferred languages spoken	☐ English	☐ Other:	
Interpreter required	☐ No	☐ Yes, comments:	
Country of birth	☐ Australia	☐ Other:	

Patient wellbeing assessment	
Reasons for presenting
Consider asking:
•	What are the patient’s current mental health issues?
•	What requests and hopes does the patient have?	
	
Patient history
Record:
•	relevant medical/biological information
•	mental health/psychological information
•	social history		
Medications and psychotropics (if relevant)
Consider asking about:
•	current medications
•	date of commencement/recent change of dose
•	medications previously prescribed
		
Results of the Mental State Examination
Record:
•	appearance, cognition, thought process, thought content, attention, memory, insight, behaviour, speech, mood and affect, perception, judgement, orientation
		
Risk assessment 
Note any identified risks, including risks of self-harm and harm to others, ideation/thoughts, intent or plans

	
Assessment/outcome tool used and the results 
(except where clinically inappropriate or culturally unsafe)		
Provisional diagnosis of mental health disorder
		
Case formulation
Consider:
•	patient’s perception of the origin of their illness, spiritual views and beliefs
•	presenting
•	predisposing
•	precipitating
•	perpetuating
•	protective	
	
Setting personal recovery goals: Considerations
Consider asking about:
•	what recovery looks like for the patient
•	the person themselves prioritising the goal/s to focus on
•	which strengths and positive dispositions (eg abilities, talents, interests) are relevant and be can built in to pursue goals		
Personal management plan	
Identified issues/problems

	Goals
Record goals made in collaboration with the patient (also goals for future treatments, longer-term goals)
	Treatments and interventions
•	Actions and support services required to achieve patient goals
•	Actions to be taken by patient. 
Consider:
•	psychological and/or pharmacological options
•	face-to-face options
•	social prescribing
•	internet-based options:
­	myCompass 
­	THIS WAY UP 
­	MindSpot 
­	e-couch 
­	moodgym 
­	Mental Health Online 
­	OnTrack
•	Australian Psychologist Society (APS):
­	Find a Psychologist
	Referrals
Support services or local groups that are culturally appropriate.
Consider:
•	referral to internet-based mental health programs for education and/or specific psychotherapy, such as:
­	myCompass 
­	THIS WAY UP 
­	MindSpot 
­	e-couch 
­	moodgym 
­	Mental Health Online 
­	OnTrack
­	Headspace (national) 	
Intervention/relapse-prevention plan
If appropriate at this stage, note arrangements to intervene in case of relapse or crisis		
Psychoeducation provided?	☐ Yes		 ☐ No	
Patient consent for having their plan recorded in their medical records?	☐ Yes		 ☐ No	
Patient consent for sharing their plan with other healthcare providers?	☐ Yes		 ☐ No	
Plan added to the patient’s records?	☐ Yes		 ☐ No	
Completing the plan 
On completion of the plan, record (tick boxes below) that you have:
☐ Discussed the assessment with the patient
☐ Discussed all aspects of the plan and the agreed date for review
☐ Offered a copy of the plan to the patient and/or their carer (if agreed by the patient)	Date plan completed (dd/mm/yyyy)