Aboriginal and Torres Strait Islander social and emotional wellbeing plan
(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 in this Social and Emotional Wellbeing Plan.
Major headings are 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?
		
Guardianship status or nominees (for adults with reduced capacity)

Record:
•	Clear description of roles and boundaries

	
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
•	Social and emotional wellbeing (mental health/psychological information)

Family and social history
•	Is the patient in the same area as their close mob / family?
•	What are the patient’s cultural responsibilities and their relationship with the community?
•	Does the patient have strong connections with their mob/family?

Social and cultural determinants of health
•	Education level/work
•	Socioeconomic status
•	Connections with family and community
•	Stability (housing, family, relationships)
•	Other relevant cultural history

	
Results of the Mental State Examination (MSE)

Working Together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice (Table 16.2. Implications and considerations in MSEs, page 281)
		
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 and 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 (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 the patient.
Consider:
•	psychological and/or pharmacological options
•	face-to-face options
•	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)