To Drs4Drs Tasmania – call record This form is used to collect information for calls received by the Drs4Drs service Tasmania Call panel doctor - Please enter your initials Confidentiality and privacy rights explained to the caller Yes Contact type Initial contact via helpline Initial contact via email Initial contact via video conference Initial contact via website Initial contact Face to Face Initial contact via referral from another body/person eg AMA House, family, work, or other DHS Who is calling? Self Colleague Family Others... Date of contact (mm/dd/yyyy) Time of SMS from call service Contact SMS Phone call Time take to return call Within 30 minutes 31-60 minutes 61-90 minutes 90 minutes - 4 hours Estimated call duration Less than 30 minutes 30 - 60 minutes Over 60 minutes Gender of person being discussed Female Male Unspecified Location of the person being discussed TAS VIC SA ACT NSW QLD NT WA Not specified Geographic profile Metro Regional Remote Rural Not specified Practice type Medical student DIT GP Specialist Staff Specialist Private Locum Unspecified Practice status Retired Active practice Not practising (leave, suspended) Deceased Not specified Are you an international medical graduate? Yes No Not specified Employer Tasmanian Health Service Private Not relevant Not specified Presenting problem Physical health Mental health (anxiety, depression, other) Acute/Chronic stress Substance use Complaint/medico-legal/regulatory concerns Workplace difficulties Relationship difficulties Financial stress Urgency Life threatening (suicidal ideation, AMI) Urgent but not life threatening (relationship crisis) Non-urgent (Health screening, bullying in the workplace Is there any concern about risk or harm or suicide No Yes - self harm or suicide Yes - harm to others e.g. children Yes - domestic abuse Not discussed Does the person have a GP? Yes No Not known Recommended to consult GP (with assistance if required) Yes No Other referrals/recommendations Not required Specialist Legal or medical defence advice Psychologist/Consellor Social Worker (Medical Benevolent Association) Medical Council Peer support e.g. D&A, Balint group, Hand in Hand Specialised online support e.g. TEN, This Way Up EAP type programs e.g. Drs4Drs, College programs Other phone support e.g. 1800 RESPECT, Lifeline Mental Health Line Emergency services, eg, Ambulance PACER Timeframe for Referral service – urgency Required to be seen face to face/phone within 24 hours (urgent) Required to be seen face to face/phone within 7 days (semi-urgent) Routine appointment – face to face/phone (non-urgent) Will you or did you spend time organising follow up support for the person being discussed? Yes No Please estimate the amount of time needed for this follow up Urgent Not required Less than 30 minutes Less than an hour More than an hour Any additional (non-identifying) comments Do you have an agreed case management plan? Yes No