CMH – Letter to GP

[textarea cols="30" rows="1" default="Dr NAME"]
[textarea cols="30" rows="5" default="Address"]

PATIENT DETAILS:

Name: [textarea cols=40 rows=1 default="patient name"]
Address: [textarea cols=70 rows=1 default="address"]
Date of birth: [textarea cols=10 rows=1 default="DOB"]

Dear Dr [text default=""],

I am writing to advise that your patient was referred to Community Mental Health for: assessment, treatment, monitoring, care planning, and linking with rehabilitation and support services. Their treating psychiatrist in our service is [textarea cols=30 rows=1 default="Dr Name"].

REFFERAL DETAILS:

Referred by: [textarea cols=40 rows=1 default="referrer"]
Reason for referral: [textarea cols=60 rows=1 default="reason"]

PRESENTING CONCERNS:

On admission, [text default="Patient Name"] identified the following concerns:

[textarea cols=60 rows=1 default="Concern"]
[textarea cols=60 rows=1 default="Concern"]
[textarea cols=60 rows=1 default="Concern"]
[textarea cols=60 rows=1 default="Concern"]
[textarea cols=60 rows=1 default="Concern"]
[textarea cols=60 rows=1 default="Concern"]

DIAGNOSTIC IMPRESSION:

[text default="PATIENT"] is experiencing symptoms consistent with a [checkbox name="neurodev" value="Neurodevelopmental Disorder;"][conditional field="neurodev" condition="(neurodev).is('Neurodevelopmental Disorder;')"] in particular, [checkbox value="Intellectual Disability|Communication Disorder|Social Communication Disorder|Autism Spectrum Disorder|Motor Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="schizo" value="Schizophrenia Spectrum Disorder;"][conditional field="schizo" condition="(schizo).is('Schizophrenia Spectrum Disorder;')"] in particular, [checkbox value="Delusional Disorder|Brief Psychotic Disorder|Schizophreniform Disorder|Schizophrenia|Schizoaffective Disorder|Substance Induced Psychotic Disorder|Psychotic Disorder due to a Medical Condition|Catatonia associated with another Mental Disorder|Catatonia Disorder due to another Medical Condition|Unspecified Catatonia|Other Specified Schizophrenia Spectrum and other Psychotic Disorder|Unspecified Schizophrenia Spectrum and
other Psychotic Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="bipol" value="Bipolar and Related Disorder;"][conditional field="bipol" condition="(bipol).is('Bipolar and Related Disorder;')"] in particular, [checkbox value="Bipolar I Disorder|Bipolar II Disorder|Cyclothymic Disorder|Substance/Medication-Induced Bipolar and Related Disorder|Bipolar and Related Disorder Due to Another Medical Condition|Other Specified Bipolar and Related Disorder|Unspecified Bipolar and Related Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="depress" value="Depressive Disorder;"][conditional field="depress" condition="(depress).is('Depressive Disorder;')"] in particular, [checkbox value="Disruptive Mood Dysregulation Disorder|Major Depressive Disorder|Persistent Depressive Disorder or Dysthymia|Premenstrual Dysphoric Disorder|Substance or Medication Induced Depressive Disorder|Depressive Disorder Due to Another Medical Condition|Other Specified Depressive Disorder|Unspecified Depressive Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="anx" value="Anxiety Disorder;"][conditional field="anx" condition="(anx).is('Anxiety Disorder;')"] in particular, [checkbox value="Separation Anxiety Disorder|Selective Mutism|Specific Phobia|Social Anxiety Disorder|Panic Disorder|Agoraphobia|Generalized Anxiety Disorder|Substance or Medication Induced Anxiety Disorder|Anxiety Disorder Due to Another Medical Condition|Other Specified Anxiety Disorder|Unspecified Anxiety Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="ocd" value="Obsessive Compulsive and related Disorder;"][conditional field="ocd" condition="(ocd).is('Obsessive Compulsive and related Disorder;')"] in particular, [checkbox value="Obsessive Compulsive Disorder|Body Dysmorphic Disorder|Hoarding Disorder|Trichotillomania|Skin Picking Disorder|Substance or Medication Induced Obsessive Compulsive and Related Disorder|Obsessive Compulsive and Related Disorder Due to Another Medical Condition|Other Specified Obsessive Compulsive and Related Disorder|Unspecified Obsessive-Compulsive and Related Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="trauma" value="Trauma and Stressor related Disorder;"][conditional field="trauma" condition="(trauma).is('Trauma and Stressor related Disorder;')"] in particular, [checkbox value="Reactive Attachment Disorder|Disinhibited Social Engagement Disorder|Posttraumatic Stress Disorder|Acute Stress Disorder|Adjustment Disorders|Other Specified Trauma and Stressor Related Disorder|Unspecified Trauma and Stressor Related Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="dissoc" value="Dissociative Disorder;"][conditional field="dissoc" condition="(dissoc).is('Dissociative Disorder;')"] in particular, [checkbox value="Dissociative Identity Disorder|Dissociative Amnesia|Depersonalization Derealization Disorder|Other Specified Dissociative Disorder|Unspecified Dissociative Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="somdis" value="Somatic Disorder;"][conditional field="somdis" condition="(somdis).is('Somatic Disorder;')"] in particular, [checkbox value="Somatic Symptom Disorder|Illness Anxiety Disorder|Conversion Disorder|Psychological Factors Affecting Other Medical Conditions|Factitious Disorder|Other Specified Somatic Symptom and Related Disorder|Unspecified Somatic Symptom and Related Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="feeddis" value="Feeding and Eating Disorder;"][conditional field="feeddis" condition="(feeddis).is('Feeding and Eating Disorder;')"] in particular, [checkbox value="Pica|Rumination Disorder|Avoidant-Restrictive Food Intake Disorder|Anorexia Nervosa|Bulimia Nervosa|Binge-Eating Disorder|Other Specified Feeding or Eating Disorder|Unspecified Feeding or Eating Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="elimdis" value="Elimination Disorder;"][conditional field="elimdis" condition="(elimdis).is('Elimination Disorder;')"] in particular, [checkbox value="Enuresis|Encopresis|Other Specified Elimination Disorder|Unspecified Elimination Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="sleepdis" value="Sleep Wake Disorder;"][conditional field="sleepdis" condition="(sleepdis).is('Sleep Wake Disorder;')"] in particular, [checkbox value="Insomnia Disorder|Hypersomnolence Disorder|Narcolepsy"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="bresledis" value="Breathing Related Sleep Disorder;"][conditional field="bresledis" condition="(bresledis).is('Breathing Related Sleep Disorder;')"] in particular, [checkbox value="Obstructive Sleep Apnea|Hypopnea|Central Sleep Apnea|Sleep-Related Hypoventilation|Circadian Rhythm Sleep-Wake Disorders"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="parasomdis" value="Parasomnia;"][conditional field="parasomdis" condition="(parasomdis).is('Parasomnia;')"] in particular, [checkbox value="Sleepwalking|Sleep Terrors|Nightmare Disorder|Rapid Eye Movement Sleep Behavior Disorder|Restless Legs Syndrome|Substance or Medication-Induced Sleep Disorder|Other Specified Insomnia Disorder|Unspecified Insomnia Disorder|Other Specified Hypersomnolence Disorder|Unspecified Hypersomnolence Disorder|Other Specified Sleep-Wake Disorder|Unspecified Sleep-Wake Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="sexdis" value="Sexual Dysfunction;"][conditional field="sexdis" condition="(sexdis).is('Sexual Dysfunction;')"] in particular, [checkbox value="Delayed Ejaculation|Erectile Disorder|Female Orgasmic Disorder|Female Sexual Interest-Arousal Disorder|Genito-Pelvic Pain Penetration Disorder|Male Hypoactive Sexual Desire Disorder|Premature Ejaculation|Substance or Medication-Induced Sexual Dysfunction|Other Specified Sexual Dysfunction|Unspecified Sexual Dysfunction"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="gendis" value="Gender Dysphoria;"][conditional field="gendis" condition="(gendis).is('Gender Dysphoria;')"] in particular, [checkbox value="Gender Dysphoria|Other Specified Gender Dysphoria|Unspecified Gender Dysphoria"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="conddis" value="Disruptive Impulse-Control and Conduct Disorder;"][conditional field="conddis" condition="(conddis).is('Disruptive Impulse-Control and Conduct Disorder;')"] in particular, [checkbox value="Oppositional Defiant Disorder|Intermittent Explosive Disorder|Conduct Disorder|Antisocial Personality Disorder|Pyromania|Kleptomania|Other Specified Disruptive Impulse-Control and Conduct Disorder|Unspecified Disruptive Impulse-Control and Conduct Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="conddis" value="Disruptive Impulse-Control and Conduct Disorder;"][conditional field="conddis" condition="(conddis).is('Disruptive Impulse-Control and Conduct Disorder;')"] in particular, [checkbox value="Oppositional Defiant Disorder|Intermittent Explosive Disorder|Conduct Disorder|Antisocial Personality Disorder|Pyromania|Kleptomania|Other Specified Disruptive Impulse-Control and Conduct Disorder|Unspecified Disruptive Impulse-Control and Conduct Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="subsdis" value="Substance and Addictive Disorder;"][conditional field="subsdis" condition="(subsdis).is('Substance and Addictive Disorder;')"] in particular, [checkbox value="Substance-Related Disorders|Substance Use Disorders|Substance-Induced Disorders|Substance Intoxication and Withdrawal|Substance or Medication-Induced Mental Disorders|Alcohol-Related Disorders|Alcohol Use Disorder|Alcohol Intoxication|Alcohol Withdrawal|Other Alcohol-Induced Disorders|Unspecified Alcohol-Related Disorder|Caffeine-Related Disorders|Caffeine Intoxication|Caffeine Withdrawal|Other Caffeine-Induced Disorders|Unspecified Caffeine-Related Disorder|Cannabis-Related Disorders|Cannabis Use Disorder|Cannabis Intoxication|Cannabis Withdrawal|Other Cannabis-Induced Disorders|Unspecified Cannabis-Related Disorder|Hallucinogen-Related Disorders|Phencyclidine Use Disorder|Other Hallucinogen Use Disorder|Phencyclidine Intoxication|Other Hallucinogen Intoxication|Hallucinogen Persisting Perception Disorder|Other Phencyclidine-Induced Disorders|Other Hallucinogen-Induced Disorders|Unspecified Phencyclidine-Related Disorder|Unspecified Hallucinogen-Related Disorder|Inhalant-Related Disorders|Inhalant Use Disorder|Inhalant Intoxication|Other Inhalant-Induced Disorders|Unspecified Inhalant-Related Disorder|Opioid-Related Disorders|Opioid Use Disorder|Opioid Intoxication|Opioid Withdrawal|Other Opioid-Induced Disorders|Unspecified Opioid-Related Disorder|Sedative Hypnotic or Anxiolytic-Related Disorders|Sedative, Hypnotic or Anxiolytic Use Disorder|Sedative, Hypnotic, or Anxiolytic Intoxication|Sedative Hypnotic or Anxiolytic Withdrawal|Other Sedative Hypnotic or Anxiolytic-Induced Disorders|Unspecified Sedative Hypnotic or Anxiolytic-Related Disorder|Stimulant-Related Disorders|Stimulant Use Disorder|Stimulant Intoxication|Stimulant Withdrawal|Other Stimulant-Induced Disorder|Tobacco Use Disorder|Tobacco Withdrawal|Other Tobacco-Induced Disorders|Unspecified Tobacco-Related Disorder|Other or Unknown Substance–Related Disorders|Other or Unknown Substance Use Disorder|Other or Unknown Substance Intoxication|Other or Unknown Substance Withdrawal|Other or Unknown Substance–Induced Disorders|Unspecified Other or Unknown Substance–Related Disorder|Gambling Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="necogdis" value="Neurocognitive Disorder;"][conditional field="necogdis" condition="(necogdis).is('Neurocognitive Disorder;')"] in particular, [checkbox value="Delirium|Other Specified Delirium|Unspecified Delirium|Major Neurocognitive Disorder|Mild Neurocognitive Disorder|Major or Mild Neurocognitive Disorder Due to Alzheimers Disease|Major or Mild Frontotemporal Neurocognitive Disorder|Major or Mild Neurocognitive Disorder With Lewy Bodies|Major or Mild Vascular Neurocognitive Disorder|Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury|Substance/Medication-Induced Major or Mild Neurocognitive Disorder|Major or Mild Neurocognitive Disorder Due to HIV Infection|Major or Mild Neurocognitive Disorder Due to Prion Disease|Major or Mild Neurocognitive Disorder Due to Parkinson’s Disease|Major or Mild Neurocognitive Disorder Due to Huntington’s Disease|Major or Mild Neurocognitive Disorder Due to Another Medical Condition|Major or Mild Neurocognitive Disorder Due to Multiple Etiologies|Unspecified Neurocognitive Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="persdis" value="Personality Disorder or Trait;"][conditional field="persdis" condition="(persdis).is('Personality Disorder or Trait;')"] in particular, [checkbox value="General Personality Disorder|Cluster A - Paranoid Personality Disorder|Cluster A - Schizoid Personality Disorder|Cluster A - Schizotypal Personality Disorder|Cluster B - Antisocial Personality Disorder|Cluster B - Borderline Personality Disorder|Cluster B - Histrionic Personality Disorder|Cluster B - Narcissistic Personality Disorder|Cluster C - Avoidant Personality Disorder|Cluster C - Dependent Personality Disorder|Cluster C - Obsessive-Compulsive Personality Disorder|Other Personality Change Due to Another Medical Condition|Other Specified Personality Disorder|Unspecified Personality Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="parapdis" value="Paraphilic Disorder;"][conditional field="parapdis" condition="(parapdis).is('Paraphilic Disorder;')"] in particular, [checkbox value="Voyeuristic Disorder|Exhibitionistic Disorder|Frotteuristic Disorder|Sexual Masochism Disorder|Sexual Sadism Disorder|Pedophilic Disorder|Fetishistic Disorder|Transvestic Disorder|Other Specified Paraphilic Disorder|Unspecified Paraphilic Disorder"] [textarea cols=80 rows=5 default=""][/conditional][checkbox name="otherdis" value="Other Mental Disorders;"][conditional field="otherdis" condition="(otherdis).is('Other Mental Disorders;')"] in particular, [checkbox value="Other Specified Mental Disorder Due to Another Medical Condition|Unspecified Mental Disorder Due to Another Medical Condition|Other Specified Mental Disorder|Unspecified Mental Disorder"][/conditional].

SYMPTOM SERVERITY:

My assessment rated the severity of their symptoms as [select name="severity" value="normal, not at all ill|mildly ill|moderately ill|markedly ill|severely ill|among the most extremely ill patients"]. 

FACTORS IMPACTING ON REVOVERY:

[checkbox value="None identified|substance use|feels stigmatized|social isolation|lacks supportive relationships|poor insight|denies illness|poor judgment|low social confidence|feels hopeless|symptom severity|poor treatment adherence|side effects from medication|family denial of illness|avoidant coping behaviours|disorganised lifestyle|chaotic family life|unmotivated for change|low self-esteem|identifies with a sick role|external locus of control|poor physical health|complex medical co-morbidities|background of adversity|secondary gain from remaining sick"].

FACTORS PROMOTING RECOVERY:

[checkbox value="none identified|social connectedness|has a positive identity|has aspirations for the future|feels empowered and in control|is resourceful|is resilient|is courageous|has strong spiritual beliefs|has meaningful occupations|is fit and healthy|is flexible and accommodating|has stable housing|is financially secure|feels self-determination|engaged in treatment|healthy lifestyle|positive attitude|feels hopeful|desires positive change|supported by family|good response to treatment|good coping skills|accessing community supports|positive self-image|internal locus of control"].
 
SUICIDE RISK:

[text default="Patient Name"] reported: [select value="no current ideation, plan, or intent|past ideation only|past ideation and plan only|past ideation, plan, and intent|previous attempt|current ideation, but no current plan or intent|current ideation and has a plan, but no current intent|current ideation, has a plan, and expressed intent"].

CURRENT MEDICATIONS:

[textarea cols=60 rows=10 default="Medications]

ACTION PLANNED:

[textarea cols=60 rows=20 default="Action"]

I am available to discuss the patient with you or provide any further information should you require this. 

Yours sincerely,


Clincian Name
Clinical Title
Community Mental Health
Tel: [textarea cols=10 rows=1 default="reason"]