Better Access mental health referral template

Australian documentation guide

Give the receiving professional a clear request and the relevant story behind it. Use this letter body for a mental health referral, with the clinician's assessment, requested service and permission to share information clearly recorded.

The blank template

REASON FOR REFERRAL: [ ]
PROVISIONAL DIAGNOSIS: [ ]
RELEVANT HISTORY: [ ]
CURRENT MEDICATIONS: [ ]
ALLERGIES & ADVERSE REACTIONS: [ ]
RISK / SAFETY: [ ]
MANAGEMENT TO DATE: [ ]
REFERRAL REQUEST: [ ]
PATIENT CONSENT TO SHARE: [ ]

How to fill it in

Copy the blank template into your record system.
Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

A helpful referral gives the receiving professional a clear question and enough relevant context to understand it. This template covers the clinical body. Add the actual patient identifiers, referring-practitioner details, signature and date in your sending system, as set out by Services Australia.

State the profession or service requested. A named provider is optional under the MBS referral requirements; include one if chosen. A treatment plan and referral are separate documents, and eligibility needs its own check.

Reason for referral

Explain what help is being requested and why, using the clinician’s stated reason and the person’s goals. “Psychology assessment” and “request for a further course of treatment” tell the reader different things.

Name the requested profession or service even if the person has not chosen a provider. Keep urgency and treatment approach to what the clinician stated. A referral does not establish acceptance by the receiving service.

Provisional diagnosis

Use the referring clinician’s diagnosis and level of certainty. Keep “working diagnosis”, “established diagnosis” or “diagnosis not stated” consistent throughout the letter.

If no diagnosis was stated, leave that gap visible. Symptoms can still be described faithfully; the letter must not turn them or a medicine name into a diagnosis. Any assessment needed belongs with the clinician.

Relevant history

Include the story needed to understand the request: what the person reports, how things have changed, effects on daily life and previous care. Identify another person’s account or records that were unavailable.

State whether the relevant plan has been prepared, is being prepared or has not been confirmed. Share relevant information rather than copying unrelated sensitive history from an older record.

Current medications

List current medicines and directions where known, with their source. Show when use is reported, a list is old or a product is still unnamed.

A medicine discussed is not necessarily treatment started. Keep missing doses and uncertain use visible; they do not supply a diagnosis or adherence finding.

Allergies and adverse reactions

Include the substance, reaction and source where known. “No known medicine allergy, reported by the person” tells the reader how that information was obtained.

An allergy history not obtained remains a required gap. Keep incomplete or disputed reaction information visible instead of turning it into a negative finding.

Risk and safety

Describe the discussion, the referring clinician’s assessment and any agreed actions, with timing and limits. Make unfinished assessment clear.

A denial of current suicidal thoughts is one answer, not a conclusion of overall safety. [not stated] must not become “safe for routine referral”. Include a risk level or safety plan only when the clinician actually stated it.

Management to date

Summarise what has happened so far and any response discussed. Keep treatment offered, accepted, started and completed distinct.

Name the plan or other documents being supplied and check that they are actually attached. A mention of a plan does not show that its contents were reviewed or shared with permission.

Referral request

State the profession, service and course requested by the clinician. For Better Access, include the actual number of services and whether the relevant plan has been prepared, as Services Australia explains.

Record the referring practitioner and practice. For GP and prescribed medical practitioner referrals, the MyMedicare-registered practice or usual medical practitioner requirement applies from 1 November 2025. Direct referrals from psychiatrists and paediatricians are also accepted and are exempt from that practice requirement. The Department of Health’s professional fact sheet explains the different referral pathways. Check current referral conditions, eligibility and prior use separately. Leave the count to the clinician’s request; neither a standard allocation nor unused entitlements can be assumed. “Discuss psychology” is not an issued referral.

Note who agreed, which information may be shared and with whom. Keep any limits or agreed carer involvement clear. If a provider is still to be chosen, record the sharing arrangement actually discussed.

Agreement to treatment and permission to send information are separate facts. Check consent before sending to the actual recipient.

Common omissions

Check the requested profession, service count, plan status, risk-assessment limits and sharing consent. The letter also needs the actual identifiers, practitioner details, signature and date. Add a named provider when chosen; its absence alone does not make the referral invalid.

Review before sending

Read the request and sensitive information against the record. Check attachments, consent and current programme requirements. The examples below are drafts with limits left visible, not letters ready to send. The clinician must explicitly confirm generated letters.

Worked examples

A psychology referral draft under an existing plan, with risk history still incomplete

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR REFERRAL: Fictional GP referral to a psychologist for assessment and psychological treatment of anxiety symptoms affecting attendance at work. Person and GP discussed this referral today.
PROVISIONAL DIAGNOSIS: GP states a working diagnosis of generalised anxiety disorder. The wording is the GP's assessment, not a diagnosis inferred by the letter.
RELEVANT HISTORY: Person reports persistent worry and disrupted sleep over four months, with three missed workdays in the past month. They previously attended counselling but the earlier service record is unavailable. Relevant Mental Health Treatment Plan is documented separately in the fictional practice record.
CURRENT MEDICATIONS: Person reports no regular prescription medicine and occasional use of an unnamed herbal product; ingredients and directions remain unverified.
ALLERGIES & ADVERSE REACTIONS: Person reports no known medicine allergy or adverse reaction. This has not been checked against other records.
RISK / SAFETY: Person denies current suicidal thoughts when asked. GP records that prior self-harm and safeguarding history remain to be clarified; no overall risk category is assigned in this extract.
MANAGEMENT TO DATE: GP discussed treatment options and the person agreed to the psychology referral. The separately documented plan records agreed goals and follow-up; this letter does not reproduce that full assessment.
REFERRAL REQUEST: GP requests an initial course of four individual psychology services under the documented Mental Health Treatment Plan, with a report after the course. Eligibility and prior service use still need checking before issue; four is the fictional clinician's request, not a default allocation.
PATIENT CONSENT TO SHARE: Person agrees to send this referral and the relevant plan information to the selected psychology service. No permission to contact family members is recorded.

A referral draft that cannot yet be issued