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Dear Dr. Johnson, I am writing to refer Mrs. Emily Thompson, a 32-year-old primigravida, for antenatal care. Mrs. Thompson has recently confirmed her pregnancy and requires comprehensive prenatal management. Given her medical history and current pregnancy status, I believe she would benefit from your expertise in obstetrics. Please find below the relevant patient information and medical details to assist in her care. Patient Information • Name: Emily Thompson • Date of Birth: 15/09/1991 • Address: 123 Maple Street, Riverdale, NY 10463 • Contact Number: (718) 555-1234 Current Pregnancy • LMP: 03/01/2023 • EDD: 10/08/2023 • Ultrasound findings: Viable intrauterine pregnancy, CRL consistent with 8 weeks gestation Obstetric History • G1P0 • No previous pregnancies or miscarriages Medical History • Mild asthma, well-controlled • Appendectomy (2015) • Allergic to penicillin Family History • Maternal: Hypertension • Paternal: Type 2 diabetes Medications • Albuterol inhaler (as needed) • Prenatal vitamins Social and Demographic Data • Occupation: Elementary school teacher • Non-smoker • No alcohol consumption since pregnancy confirmation • No recreational drug use Mrs. Thompson has undergone initial blood work, including a complete blood count, blood type, and Rh factor. Her pap smear is up to date, performed six months ago with normal results. I have also requested routine first-trimester screening tests, including HIV, hepatitis B, and rubella antibody titers. Thank you for accepting this referral. Please do not hesitate to contact me if you require any additional information or have any concerns regarding Mrs. Thompson's care.
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Antenatal Care referral

Thank you for referring John Doe to our clinic for lower back pain. John Doe's initial appointment was on 15th May 2023. John Doe presented with: • Severe lower back pain, rated 8/10 on the pain scale • Limited range of motion in lumbar spine, particularly in flexion • Positive straight leg raise test at 45 degrees • Decreased sensation in L5 dermatome of left foot The plan with physiotherapy is: manual therapy for the lumbar spine to improve mobility and reduce pain, home-based core strengthening exercises, and a progressive walking program to improve overall function and endurance. If you have any questions regarding John Doe's physiotherapy, please do not hesitate to contact me on 0412 345 678. Thank you again for referring John Doe.
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EPC Initial Letter

Home: • The patient resides at 123 Maple Street, Suburbia, with her parents and younger sister • Recent changes include moving to a new school district 6 months ago • Reports increased stress due to academic pressure and making new friends • Spends approximately 4 hours daily on social media and gaming Education & Employment: • Currently enrolled as a junior at Suburbia High School • Maintains a B average but struggling in mathematics • Part-time job at local grocery store (10 hours/week) • Plans to apply to state universities next year Eating & Exercise: • Weight: 65 kg, height: 165 cm • Skips breakfast regularly, tends to snack late at night • Participates in school soccer team, practices 3 times/week • Menstrual cycles regular, every 28-30 days Activities: • Member of school drama club, rehearsals twice weekly • Plays guitar as a hobby, self-taught • Screen time averages 6 hours daily (including homework) Drugs & Alcohol: • Denies personal use of alcohol or drugs • Reports some friends experimenting with marijuana at parties • No known substance use in immediate family Sexuality & Gender: • Identifies as female, uses she/her pronouns • Currently in a 6-month relationship with male classmate • Sexually active, uses condoms for contraception • No history of pregnancies or STIs Suicide, Depression & Self-Harm: • Reports feeling overwhelmed and sad occasionally • Sleep disturbances: difficulty falling asleep, averages 6 hours/night • Denies self-harm behaviors or suicidal ideation • No history of diagnosed mental health conditions Safety: • No serious injuries in past year • Reports being cautious about online privacy • No exposure to domestic violence or abuse • No involvement in criminal activities
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HEADS

Interview Context: I met with Sarah Johnson and her husband, Tom. Sarah expressed concern about her increasing anxiety levels and their impact on her daily life. Tom provided additional context and observations regarding Sarah's symptoms. Profile: Sarah Johnson is a 35-year-old married woman living in suburban Melbourne. She works as a primary school teacher and enjoys gardening and yoga in her free time. Presenting Complaint: Sarah is seeking help for worsening anxiety symptoms that are interfering with her work and personal life. History of Presenting Complaint: Anxiety symptoms began six months ago, gradually intensifying. Sarah experiences frequent worry about work performance, health, and family matters. Difficulty controlling these thoughts, often leading to physical symptoms. Anxiety symptoms: Excessive worry about various aspects of life. Racing thoughts, difficulty concentrating. Physical symptoms include rapid heartbeat, sweating, and trembling. Avoids social gatherings and public speaking at work. Mood symptoms: Low mood accompanying anxiety episodes. Feelings of worthlessness and guilt, particularly related to work performance. No significant changes in appetite or weight. Vegetative features: Insomnia, taking 1-2 hours to fall asleep. Wakes multiple times during night. Fatigue throughout the day, affecting work performance. Concentration difficulties, especially during anxious periods. No significant diurnal mood variation. Manic or Psychotic features: No manic symptoms or episodes reported. No hallucinations, delusions, or other psychotic features observed or reported. Risks: No current suicidal ideation or intent. No history of self-harm or suicide attempts. No homicidal ideation or aggressive behavior. Recent stressors: Increased workload at school. Mother-in-law diagnosed with cancer three months ago. Financial concerns due to recent home renovation. Attributes anxiety to work stress and family health worries. Overall functioning impaired, particularly in work and social domains. Past History: - Mild depressive episode at age 25. - Appendectomy at age 18. - Asthma diagnosed in childhood, well-controlled. Medication: - Salbutamol inhaler PRN for asthma - Trial of sertraline 50mg daily for 2 months (discontinued due to side effects) Alcohol / Substance Use: - Alcohol: 1-2 glasses of wine per week, socially - No illicit substance use - No smoking Family History: - Mother: Generalized Anxiety Disorder. - Father: Type 2 Diabetes. - Maternal grandmother: Depression. Developmental History: - Unremarkable pregnancy and delivery - Met developmental milestones appropriately - Described as a shy child, difficulty making friends in primary school - Parents divorced when patient was 14, experienced adjustment difficulties - Excelled academically throughout schooling Mental State Examination: Appropriately dressed, well-groomed woman appearing stated age. Mild psychomotor agitation, fidgeting with hands. Speech normal in rate and volume. Affect anxious, mood congruent. No perceptual disturbances. Thought process logical and coherent. No evidence of thought disorder or delusions. Cognition intact, oriented to time, place, and person. Good rapport established. Partial insight into condition. Judgment unimpaired. Impression: Sarah presents with symptoms consistent with Generalized Anxiety Disorder (GAD) as per DSM-5 criteria. Biological factors include genetic predisposition (family history of anxiety). Psychological factors involve perfectionist tendencies and negative self-talk. Social stressors include work pressure and family illness. Precipitating factors: increased work responsibilities and mother-in-law's cancer diagnosis. Maintaining factors: avoidance behaviors and rumination. Protective factors include supportive spouse and engagement in yoga. No immediate risk to self or others identified. Differential diagnosis includes Adjustment Disorder with Anxiety. Plan: - Commence cognitive-behavioral therapy (CBT) for anxiety management - Consider trial of SSRI (e.g., escitalopram 10mg daily) for symptom relief - Encourage continuation of yoga and introduction of mindfulness practices - Provide psychoeducation on anxiety and sleep hygiene - Review in 4 weeks to assess progress and medication response if initiated - Liaise with GP for ongoing physical health monitoring
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Psychiatry Comprehensive Assessment

Patient Assessment – Mental Health - Persistent low mood for 3 months - Difficulty sleeping, averaging 4-5 hours per night - Loss of interest in previously enjoyed activities - Fatigue and low energy levels throughout the day - Poor concentration affecting work performance - Occasional suicidal thoughts without plan or intent - Expresses feelings of worthlessness, stating "I feel like I'm failing at everything" Mental Health History - No previous mental health diagnoses - Brief counseling during university for stress management (5 years ago) - No history of psychiatric medications - Never seen a psychiatrist Social/Family History - Single, living alone in a rented apartment - Full-time employment as an accountant - Limited social support network - Mother diagnosed with depression in her 40s - No other known family history of mental health issues Mental Status Examination - Appearance: Adequately groomed, slightly disheveled - Behavior: Slow movements, slumped posture - Speech: Slow rate, low volume - Mood: Depressed - Affect: Flat, congruent with mood - Thought Process: Linear, goal-directed - Thought Content: No delusions or hallucinations - Insight: Partial - Judgment: Intact Outcome Measurement Tool K10: 32 Risk Assessment - Passive suicidal ideation without plan or intent - No history of self-harm - No risk to others Provisional Diagnosis - Major Depressive Disorder, single episode, moderate Issues/problems - Persistent depressive symptoms impacting daily functioning - Sleep disturbance contributing to daytime fatigue - Social isolation exacerbating low mood - Work performance affected by poor concentration Goals - Improve mood and reduce depressive symptoms - Establish healthy sleep patterns - Increase social engagement and support network - Enhance work productivity through improved concentration Actions for patient - Commence antidepressant medication as prescribed - Attend weekly psychological therapy sessions - Implement sleep hygiene techniques - Gradually increase physical activity, starting with daily 15-minute walks - Reconnect with one friend or family member each week Plan for Crisis Intervention and/or for Relapse Prevention: - Identify early warning signs of worsening mood - Develop a list of coping strategies for managing low mood - Create a safety plan for managing suicidal thoughts - Schedule regular check-ins with GP to monitor progress - Engage in regular physical activity to maintain mood stability Emergency care: Lifeline 13 11 14 : Mental Health Access Line 1800 011 511 Psycho-education performed: Yes Patient agreement to goals: Yes Copy of plan given to patient: Yes
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GP MHCP

28 June 2023 The Principal [School Name] [School Address] Dear Principal, I am writing as the treating pediatrician for [Student's Name], who has been under my care for the past three years. This letter is to provide evidence of eligibility for funding support based on the criteria outlined for funding in the Victorian school system. Statement of Disability • [Student's Name] meets the criteria for Autism Spectrum Disorder. • Diagnosis confirmed through comprehensive assessment. • Deficits in adaptive behavior and language skills are present. Supporting Documentation I have attached the following supporting documentation for your review: Autism Diagnostic Observation Schedule (ADOS) report and Adaptive Behavior Assessment System (ABAS) results. I want to highlight that [Student's Name] requires specialized support for social skills development and communication. The level of support required aligns with the criteria outlined for the Program for Students with Disabilities. Sincerely, Dr. [Clinician's Name] Pediatrician
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Medical support for School Funding

General practice templates

Templates made specifically for general practitioners
Dear Dr. Johnson, I am writing to refer Mrs. Emily Thompson, a 32-year-old primigravida, for antenatal care. Mrs. Thompson has recently confirmed her pregnancy and requires comprehensive prenatal management. Given her medical history and current pregnancy status, I believe she would benefit from your expertise in obstetrics. Please find below the relevant patient information and medical details to assist in her care. Patient Information • Name: Emily Thompson • Date of Birth: 15/09/1991 • Address: 123 Maple Street, Riverdale, NY 10463 • Contact Number: (718) 555-1234 Current Pregnancy • LMP: 03/01/2023 • EDD: 10/08/2023 • Ultrasound findings: Viable intrauterine pregnancy, CRL consistent with 8 weeks gestation Obstetric History • G1P0 • No previous pregnancies or miscarriages Medical History • Mild asthma, well-controlled • Appendectomy (2015) • Allergic to penicillin Family History • Maternal: Hypertension • Paternal: Type 2 diabetes Medications • Albuterol inhaler (as needed) • Prenatal vitamins Social and Demographic Data • Occupation: Elementary school teacher • Non-smoker • No alcohol consumption since pregnancy confirmation • No recreational drug use Mrs. Thompson has undergone initial blood work, including a complete blood count, blood type, and Rh factor. Her pap smear is up to date, performed six months ago with normal results. I have also requested routine first-trimester screening tests, including HIV, hepatitis B, and rubella antibody titers. Thank you for accepting this referral. Please do not hesitate to contact me if you require any additional information or have any concerns regarding Mrs. Thompson's care.
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Antenatal Care referral

John Smith, born on 15/03/1976 (47 years old), is married with two children aged 12 and 9. He works as a software engineer for a tech company in the city. Mr. Smith lives with his family in a suburban area and commutes to work daily. He maintains an active lifestyle, regularly participating in weekend sports activities with his children. • Current medications: Lisinopril 10mg daily for hypertension • Allergies: Penicillin (rash) • Recent vaccinations: Influenza vaccine (3 months ago) • Smoking: Non-smoker • Alcohol consumption: 2-3 standard drinks per week, usually on weekends • Hypertension diagnosed 2 years ago, well-controlled with medication • Appendectomy at age 15 • Fractured left wrist from a cycling accident 5 years ago, fully healed • Father: Type 2 diabetes diagnosed at age 60 • Mother: Breast cancer at age 55, in remission • Maternal grandmother: Osteoarthritis Mr. Smith's overall health status is generally good. He maintains a healthy weight, exercises regularly, and manages his hypertension effectively with medication. However, there are concerns about his family history of diabetes and cancer. We discussed the importance of regular check-ups, maintaining a healthy lifestyle, and being vigilant about early signs of these conditions. Mr. Smith expressed understanding and commitment to following preventive measures. • Blood pressure: 125/80 mmHg (within normal range) • BMI: 24.5 (normal weight) • Fasting blood glucose: 5.2 mmol/L (normal) • Total cholesterol: 4.8 mmol/L (within normal range) 1. Asthma: Low risk. No personal or family history. No action required. 2. Cardiovascular illness: Moderate risk due to hypertension and family history of diabetes. Action: Continue blood pressure medication and monitoring. 3. Diabetes: Moderate risk due to family history. Action: Annual blood glucose testing and lifestyle counseling. 4. Mental health: Low risk. No personal or family history. Continue monitoring during regular check-ups. 5. Arthritis: Low to moderate risk due to family history. Action: Maintain healthy weight and exercise regimen. 1. Smoking: Non-smoker. No intervention required. 2. Nutrition: Generally good. Advised to increase fruit and vegetable intake. 3. Alcohol: Low risk. Consumption within recommended limits. 4. Physical activity: Adequate. Encouraged to maintain current exercise routine. 5. Mood: No concerns. Appears to manage stress well through regular exercise and family activities. 1. Blood pressure: Well-controlled with medication. Continue monitoring. 2. Body weight: Normal BMI. Advised to maintain current weight. 3. Cholesterol: Within normal range. Recheck in 2 years. 4. Glucose metabolism: Normal. Annual testing recommended due to family history of diabetes. • Fasting lipid profile: To be scheduled in 2 years • Fasting blood glucose: Annual testing • Prostate-specific antigen (PSA) test: To be considered at age 50 or earlier if family history changes Mr. Smith was advised to maintain his current healthy lifestyle, including regular exercise and a balanced diet. We discussed the importance of stress management techniques and maintaining work-life balance. He was encouraged to continue his blood pressure medication as prescribed and attend annual check-ups to monitor his risk factors, particularly for diabetes and cardiovascular disease. Mr. Smith agreed to schedule a follow-up appointment in 12 months for reassessment and to discuss any new health concerns that may arise.
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45-49 check

Dear Dr. Emily Thompson, Thank you for agreeing to see Mrs. Sarah Johnson under the Better Access Scheme for six sessions. Your expertise in managing her current mental health concerns is greatly appreciated. Please find enclosed the Mental Health Care Plan for your review. If you require any further information or have any questions, please don't hesitate to contact me. I look forward to your assessment and recommendations for Mrs. Johnson's ongoing care. Sincerely, Dr. Michael Roberts [Signature space] Patient Problem/s • Major Depressive Disorder, Recurrent, Moderate (DSM-5: 296.32) • Generalized Anxiety Disorder (DSM-5: 300.02) Background to the current problems Mrs. Johnson, a 42-year-old female, presents with a 6-month history of worsening depressive symptoms and anxiety. She reports persistent low mood, anhedonia, fatigue, and difficulty concentrating, which have significantly impacted her daily functioning. Previous treatments include a trial of sertraline 50mg daily for 3 months, which provided minimal relief. Currently, she is taking escitalopram 10mg daily, prescribed 4 weeks ago, and attending weekly mindfulness classes. No previous psychological interventions have been attempted. Social History Mrs. Johnson is married with two children aged 10 and 12. She denies smoking or illicit drug use but reports occasional alcohol consumption (2-3 glasses of wine per week). Previously employed as a high school teacher, she is currently on leave due to her mental health concerns. Mrs. Johnson is of Caucasian descent and was born and raised in Australia. She describes a supportive family environment but feels increasingly isolated due to her symptoms. Mental State Examination • Appearance: Well-groomed, appropriate attire • Behavior: Cooperative, mildly psychomotor retarded • Speech: Normal rate and volume, slightly monotonous • Mood: Depressed • Affect: Restricted, congruent with mood • Thought form: Logical and coherent • Thought content: No delusions or obsessions noted • Perception: No hallucinations reported • Cognition: Alert and oriented, intact memory • Insight: Good • Judgment: Intact • Risk assessment: Low risk of self-harm, no suicidal ideation • Key family contact: Mr. David Johnson (husband) - 0412 345 678 Formulation Mrs. Johnson's presentation is consistent with Major Depressive Disorder and Generalized Anxiety Disorder, likely exacerbated by work-related stress and difficulty balancing family responsibilities. Her current treatment includes medication management by myself and weekly mindfulness classes. Patient education has been provided regarding the nature of depression and anxiety, the importance of adherence to medication, and the potential benefits of psychological interventions. Expectations and Concerns 1. Problem: Major Depressive Disorder and Generalized Anxiety Disorder 2. Goals: Reduce depressive symptoms, manage anxiety, improve daily functioning 3. Action/Tasks: Engage in Cognitive Behavioral Therapy, continue medication as prescribed 4. Emergency care/relapse prevention: Crisis plan discussed, including contact numbers for mental health crisis team 5. Initial action plan: Weekly therapy sessions, medication review in 4 weeks 6. Patient consent: Mrs. Johnson has provided verbal consent for this referral and sharing of information Referring GP Details Dr. Michael Roberts, MBBS, FRACGP, Greenwood Medical Centre, 123 Main Street, Sydney, NSW 2000. Phone: (02) 9876 5432. Fax: (02) 9876 5433. Provider Number: 1234567A.
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MHCP with referral to psychologist for sessions

Issues addressed in GPMP • Type 2 Diabetes Mellitus • Hypertension • Hyperlipidemia • Obesity • Osteoarthritis (knee) Current Medications Metformin 1000mg BD for diabetes. Ramipril 5mg OD for hypertension. Atorvastatin 20mg OD for hyperlipidemia. Paracetamol 1g QID PRN for osteoarthritis pain. Update of Health Issues • Type 2 Diabetes: HbA1c improved from 7.8% to 7.2%. • Hypertension: BP stable at 138/82 mmHg. • Hyperlipidemia: LDL-C reduced to 2.8 mmol/L. • Obesity: BMI decreased from 32 to 30.5 kg/m². • Osteoarthritis: Pain score reduced from 7/10 to 5/10. Goals • Type 2 Diabetes: Achieve HbA1c ≤ 7.0% within 6 months. • Hypertension: Maintain BP < 130/80 mmHg. • Hyperlipidemia: Reach LDL-C < 2.5 mmol/L in 3 months. • Obesity: Reduce BMI to < 30 kg/m² in 6 months. • Osteoarthritis: Maintain pain score ≤ 4/10. For Medication Review (DDMR)
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Outcomes since last GPMP

Mental Health Treatment Plan The patient, Sarah Thompson, has provided informed consent for this mental health care plan and agrees to share it with her psychologist, Dr. Emily Chen. Background Sarah Thompson is a 28-year-old female with a history of anxiety and depression since her late teens. She had her first mental health review with her GP at age 19, which resulted in a referral to a psychologist. Sarah attended six sessions of cognitive-behavioral therapy (CBT) but discontinued due to financial constraints. She has never been admitted to a mental health unit. Sarah was prescribed sertraline 50mg daily for depression two years ago by her previous GP but stopped taking it after three months due to side effects. No other relevant medical history was reported. Current Mental Health Issues Sarah presents with symptoms of persistent low mood, fatigue, and difficulty concentrating, which have worsened over the past six months. She reports frequent worry about her job performance and social interactions, leading to avoidance behaviors. Sarah also experiences occasional panic attacks, characterized by heart palpitations, sweating, and a sense of impending doom. These symptoms have significantly impacted her daily functioning and quality of life. Screen for mental health conditions Sarah's symptoms are consistent with major depressive disorder and generalized anxiety disorder. There is no evidence of bipolar disorder, psychosis, or eating disorders based on the current assessment. Social history Childhood: Generally happy childhood, no significant trauma or abuse reported. Grew up in a suburban area with both parents and a younger sister. Home life: Currently lives alone in a small apartment in the city. Education: Bachelor's degree in Marketing. No reported issues during her education. Employment: Works as a marketing coordinator for a medium-sized company. Recently feeling overwhelmed and anxious about job performance. Lifestyle: Non-smoker, occasional alcohol use (1-2 drinks per week), no illicit drug use. Inconsistent exercise routine. Relationships/sexuality: Single, ended a 3-year relationship 8 months ago. Reports difficulty forming new relationships due to anxiety. MSE Appearance: Well-groomed, appropriately dressed Behavior: Cooperative, maintained good eye contact, occasionally fidgety Speech: Normal rate and volume, coherent Mood: "Anxious and down" Affect: Congruent with mood, restricted range Thoughts: Logical and goal-directed, no evidence of thought disorder Perception: No hallucinations or delusions reported or observed Insight: Good insight into her mental health issues Judgement: Intact Suicidal thoughts: Denies current suicidal ideation or intent Cognition: Alert and oriented, no apparent cognitive deficits Formulation Predisposing factors: - Family history of anxiety (mother) - Perfectionist tendencies developed in childhood Precipitating factors: - Recent job promotion with increased responsibilities - End of long-term relationship 8 months ago Perpetuating factors: - Social isolation due to avoidance behaviors - Negative self-talk and catastrophic thinking - Poor sleep hygiene Protective factors: - Good insight into her condition - Supportive family - Motivation to improve mental health - Stable employment Impression Sarah presents with symptoms consistent with major depressive disorder and generalized anxiety disorder. Her anxiety appears to be significantly impacting her daily functioning and contributing to her depressive symptoms. Differential diagnoses to consider include adjustment disorder with mixed anxiety and depressed mood, given the recent life changes. Assessment tool DASS-21 scores: Depression: 24 (Severe) Anxiety: 18 (Severe) Stress: 28 (Severe) Risk assessment Suicide: Low risk. No current suicidal ideation, intent, or plan. No history of suicide attempts. Homicide: No risk. No homicidal ideation or intent reported. Self-harm: Low risk. No current self-harm behaviors or intentions reported. Goals 1. Reduce symptoms of depression and anxiety - Refer to psychologist for CBT, focusing on challenging negative thoughts and developing coping strategies - Consider reintroduction of antidepressant medication (SSRI) after discussing options and potential side effects 2. Improve social connections and reduce avoidance behaviors - Gradually increase social interactions through exposure therapy techniques - Join a local support group for individuals with anxiety and depression 3. Enhance work-life balance and stress management - Implement time management and prioritization strategies - Practice mindfulness and relaxation techniques daily Plan Referrals: 1. Psychologist: Dr. Emily Chen for CBT, 6-8 sessions initially 2. Psychiatrist: Dr. Mark Johnson for medication evaluation and management Psychoeducation on depression, anxiety, and the importance of self-care provided during the consultation. Emergency care: Lifeline 13 11 14 : Mental Health Access Line 1800 011 511 Psycho-education performed: Yes Patient agreement to goals: Yes Copy of plan given to patient: Yes Review Date: Patient is scheduled for a follow-up consultation in 4 weeks for reassessment and review of the mental health care plan. Crisis plan 1. Recognize early warning signs of worsening symptoms (e.g., increased isolation, persistent negative thoughts) 2. Utilize learned coping strategies (deep breathing, progressive muscle relaxation) 3. Reach out to a trusted friend or family member for support 4. Contact psychologist or GP if symptoms persist or worsen 5. In case of emergency or suicidal thoughts, call Lifeline (13 11 14) or go to the nearest emergency department 6. Keep a list of emergency contacts readily available, including healthcare providers and support persons
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Mental Health Care Plan

Patients attending together in an Extended Family Consultation: Mrs. Jane Smith Mr. John Smith Miss Emily Smith Mr. and Mrs. Smith, along with their daughter Emily, attended the clinic due to a family history of breast cancer. Mrs. Smith was recently diagnosed with triple-negative breast cancer at age 45, prompting concerns about potential genetic predisposition. The family sought genetic counseling to understand their risks and explore testing options. We talked through genetic testing in detail, and once I receive completed consent forms from each of the family members, we'll arrange BRCA1/2 and TP53 gene panel tests. The patients are aware that results will take approximately 4 months once they have the blood samples taken, and are aware that there could be significant implications not just for themselves but for members of the wider family should we pick up a mutation. Blood samples will be collected next week, with results expected in approximately 4 months, after which a follow-up consultation will be scheduled to discuss findings and implications. I will write to you when I see the family to discuss things further. Yours Sincerely, [Doctor's Signature]
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Family Consultation Letter

Specialist templates

Templates made specifically for specialists
Thank you for referring John Doe to our clinic for lower back pain. John Doe's initial appointment was on 15th May 2023. John Doe presented with: • Severe lower back pain, rated 8/10 on the pain scale • Limited range of motion in lumbar spine, particularly in flexion • Positive straight leg raise test at 45 degrees • Decreased sensation in L5 dermatome of left foot The plan with physiotherapy is: manual therapy for the lumbar spine to improve mobility and reduce pain, home-based core strengthening exercises, and a progressive walking program to improve overall function and endurance. If you have any questions regarding John Doe's physiotherapy, please do not hesitate to contact me on 0412 345 678. Thank you again for referring John Doe.
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EPC Initial Letter

Home: • The patient resides at 123 Maple Street, Suburbia, with her parents and younger sister • Recent changes include moving to a new school district 6 months ago • Reports increased stress due to academic pressure and making new friends • Spends approximately 4 hours daily on social media and gaming Education & Employment: • Currently enrolled as a junior at Suburbia High School • Maintains a B average but struggling in mathematics • Part-time job at local grocery store (10 hours/week) • Plans to apply to state universities next year Eating & Exercise: • Weight: 65 kg, height: 165 cm • Skips breakfast regularly, tends to snack late at night • Participates in school soccer team, practices 3 times/week • Menstrual cycles regular, every 28-30 days Activities: • Member of school drama club, rehearsals twice weekly • Plays guitar as a hobby, self-taught • Screen time averages 6 hours daily (including homework) Drugs & Alcohol: • Denies personal use of alcohol or drugs • Reports some friends experimenting with marijuana at parties • No known substance use in immediate family Sexuality & Gender: • Identifies as female, uses she/her pronouns • Currently in a 6-month relationship with male classmate • Sexually active, uses condoms for contraception • No history of pregnancies or STIs Suicide, Depression & Self-Harm: • Reports feeling overwhelmed and sad occasionally • Sleep disturbances: difficulty falling asleep, averages 6 hours/night • Denies self-harm behaviors or suicidal ideation • No history of diagnosed mental health conditions Safety: • No serious injuries in past year • Reports being cautious about online privacy • No exposure to domestic violence or abuse • No involvement in criminal activities
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HEADS

Interview Context: I met with Sarah Johnson and her husband, Tom. Sarah expressed concern about her increasing anxiety levels and their impact on her daily life. Tom provided additional context and observations regarding Sarah's symptoms. Profile: Sarah Johnson is a 35-year-old married woman living in suburban Melbourne. She works as a primary school teacher and enjoys gardening and yoga in her free time. Presenting Complaint: Sarah is seeking help for worsening anxiety symptoms that are interfering with her work and personal life. History of Presenting Complaint: Anxiety symptoms began six months ago, gradually intensifying. Sarah experiences frequent worry about work performance, health, and family matters. Difficulty controlling these thoughts, often leading to physical symptoms. Anxiety symptoms: Excessive worry about various aspects of life. Racing thoughts, difficulty concentrating. Physical symptoms include rapid heartbeat, sweating, and trembling. Avoids social gatherings and public speaking at work. Mood symptoms: Low mood accompanying anxiety episodes. Feelings of worthlessness and guilt, particularly related to work performance. No significant changes in appetite or weight. Vegetative features: Insomnia, taking 1-2 hours to fall asleep. Wakes multiple times during night. Fatigue throughout the day, affecting work performance. Concentration difficulties, especially during anxious periods. No significant diurnal mood variation. Manic or Psychotic features: No manic symptoms or episodes reported. No hallucinations, delusions, or other psychotic features observed or reported. Risks: No current suicidal ideation or intent. No history of self-harm or suicide attempts. No homicidal ideation or aggressive behavior. Recent stressors: Increased workload at school. Mother-in-law diagnosed with cancer three months ago. Financial concerns due to recent home renovation. Attributes anxiety to work stress and family health worries. Overall functioning impaired, particularly in work and social domains. Past History: - Mild depressive episode at age 25. - Appendectomy at age 18. - Asthma diagnosed in childhood, well-controlled. Medication: - Salbutamol inhaler PRN for asthma - Trial of sertraline 50mg daily for 2 months (discontinued due to side effects) Alcohol / Substance Use: - Alcohol: 1-2 glasses of wine per week, socially - No illicit substance use - No smoking Family History: - Mother: Generalized Anxiety Disorder. - Father: Type 2 Diabetes. - Maternal grandmother: Depression. Developmental History: - Unremarkable pregnancy and delivery - Met developmental milestones appropriately - Described as a shy child, difficulty making friends in primary school - Parents divorced when patient was 14, experienced adjustment difficulties - Excelled academically throughout schooling Mental State Examination: Appropriately dressed, well-groomed woman appearing stated age. Mild psychomotor agitation, fidgeting with hands. Speech normal in rate and volume. Affect anxious, mood congruent. No perceptual disturbances. Thought process logical and coherent. No evidence of thought disorder or delusions. Cognition intact, oriented to time, place, and person. Good rapport established. Partial insight into condition. Judgment unimpaired. Impression: Sarah presents with symptoms consistent with Generalized Anxiety Disorder (GAD) as per DSM-5 criteria. Biological factors include genetic predisposition (family history of anxiety). Psychological factors involve perfectionist tendencies and negative self-talk. Social stressors include work pressure and family illness. Precipitating factors: increased work responsibilities and mother-in-law's cancer diagnosis. Maintaining factors: avoidance behaviors and rumination. Protective factors include supportive spouse and engagement in yoga. No immediate risk to self or others identified. Differential diagnosis includes Adjustment Disorder with Anxiety. Plan: - Commence cognitive-behavioral therapy (CBT) for anxiety management - Consider trial of SSRI (e.g., escitalopram 10mg daily) for symptom relief - Encourage continuation of yoga and introduction of mindfulness practices - Provide psychoeducation on anxiety and sleep hygiene - Review in 4 weeks to assess progress and medication response if initiated - Liaise with GP for ongoing physical health monitoring
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Psychiatry Comprehensive Assessment

Patient Assessment – Mental Health - Persistent low mood for 3 months - Difficulty sleeping, averaging 4-5 hours per night - Loss of interest in previously enjoyed activities - Fatigue and low energy levels throughout the day - Poor concentration affecting work performance - Occasional suicidal thoughts without plan or intent - Expresses feelings of worthlessness, stating "I feel like I'm failing at everything" Mental Health History - No previous mental health diagnoses - Brief counseling during university for stress management (5 years ago) - No history of psychiatric medications - Never seen a psychiatrist Social/Family History - Single, living alone in a rented apartment - Full-time employment as an accountant - Limited social support network - Mother diagnosed with depression in her 40s - No other known family history of mental health issues Mental Status Examination - Appearance: Adequately groomed, slightly disheveled - Behavior: Slow movements, slumped posture - Speech: Slow rate, low volume - Mood: Depressed - Affect: Flat, congruent with mood - Thought Process: Linear, goal-directed - Thought Content: No delusions or hallucinations - Insight: Partial - Judgment: Intact Outcome Measurement Tool K10: 32 Risk Assessment - Passive suicidal ideation without plan or intent - No history of self-harm - No risk to others Provisional Diagnosis - Major Depressive Disorder, single episode, moderate Issues/problems - Persistent depressive symptoms impacting daily functioning - Sleep disturbance contributing to daytime fatigue - Social isolation exacerbating low mood - Work performance affected by poor concentration Goals - Improve mood and reduce depressive symptoms - Establish healthy sleep patterns - Increase social engagement and support network - Enhance work productivity through improved concentration Actions for patient - Commence antidepressant medication as prescribed - Attend weekly psychological therapy sessions - Implement sleep hygiene techniques - Gradually increase physical activity, starting with daily 15-minute walks - Reconnect with one friend or family member each week Plan for Crisis Intervention and/or for Relapse Prevention: - Identify early warning signs of worsening mood - Develop a list of coping strategies for managing low mood - Create a safety plan for managing suicidal thoughts - Schedule regular check-ins with GP to monitor progress - Engage in regular physical activity to maintain mood stability Emergency care: Lifeline 13 11 14 : Mental Health Access Line 1800 011 511 Psycho-education performed: Yes Patient agreement to goals: Yes Copy of plan given to patient: Yes
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GP MHCP

28 June 2023 The Principal [School Name] [School Address] Dear Principal, I am writing as the treating pediatrician for [Student's Name], who has been under my care for the past three years. This letter is to provide evidence of eligibility for funding support based on the criteria outlined for funding in the Victorian school system. Statement of Disability • [Student's Name] meets the criteria for Autism Spectrum Disorder. • Diagnosis confirmed through comprehensive assessment. • Deficits in adaptive behavior and language skills are present. Supporting Documentation I have attached the following supporting documentation for your review: Autism Diagnostic Observation Schedule (ADOS) report and Adaptive Behavior Assessment System (ABAS) results. I want to highlight that [Student's Name] requires specialized support for social skills development and communication. The level of support required aligns with the criteria outlined for the Program for Students with Disabilities. Sincerely, Dr. [Clinician's Name] Pediatrician
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Medical support for School Funding

Dr. Emily Thompson, PhD Clinical Psychologist (PSY0012345) Thompson Mental Health Services 123 Wellness Street, Melbourne VIC 3000 Phone: (03) 9876 5432 | Email: dr.thompson@tmhs.com.au I have been treating Sarah Johnson (DOB: 15/09/1990) for major depressive disorder and generalized anxiety disorder since January 2020. These conditions, diagnosed in 2018, are permanent and significantly impact her daily functioning. Current treatment includes cognitive-behavioral therapy and medication management, with partial response. Sarah struggles with social isolation, difficulty maintaining employment, and performing daily tasks. I strongly recommend NDIS support to improve her quality of life and enhance her ability to manage daily activities. Evidence-based interventions and ongoing support are crucial for Sarah's progress. I confirm the accuracy of the information provided herein, acknowledging that my opinion may be subject to revision should additional relevant information become available. Dr. Emily Thompson Provider Number: 1234567A
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NDIS Psychological Assessment

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