Events
Expression of interest
Call record
24/7 Help Line 1300 374 377
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Events
Expression of interest
Expression of interest
24/7 Help Line 1300 374 377
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