GP Name/Practice
Patient's Name
*
First Name
Last Name
Date of Birth
MM
DD
YYYY
Patient's email address
Phone:
Address
Carer details and/or emergency contact(s)
AHP or Nurse currently involved in patient care
Other care plan?
EG GPMP/TCA
Presenting Issue(s)
What are the patient's current mental health issues
Presenting issues (other)
Description of symptoms
Severity, History, Frequency and other salient features
Biological
Psychological
Social History
Relationships, children, migration, employment
Family history of psychological disorders
Substance use or physical health problems
Any other relevant details
Medications
Allergies
Results of Mental state examination
Risks and Co-morbidities
Note any associated risks and co-morbidities
Suicide risk
*
Outcome tool used
Results:
Diagnosis
Patient Needs/Main Issues
Goals
Record the mental health goals agreed to by the patient and GP and any actions the patient will need to take
Treatments
Treatments, actions and support services to achieve patient goals
Referrals
Note: Referrals to be provided by GP as required, in up to two groups of six sessions. The need for the second group of sessions to be reviewed after the initial six sessions
Crisis/Relapse
If required, note the arrangements for crisis intervention and/or relapse
Appropriate psycho-education provided
Plan added to the patient's records
Copy (or parts) of the plan offered to other providers
Completing the Plan
The GP has discussed with the patient:
- the assessment;
- all aspects of the plan and the agreed date for review; and
- offered a copy of the plan to the patient and/or their carer (if agreed by patient)
Date plan completed
MM
DD
YYYY
Review Date
MM
DD
YYYY
Review comments
Progress on actions and tasks. If necessary additional interventions or referrals required. Note if an extension of another six sessions of psychological treatment is necessary
Outcome tool results on review
