GP Mental Health Treatment Plan (MHTP)
Assessment Session Template:
General practitioners in Australia are required to complete a GP Mental Health Treatment Plan (MHTP) under the Better Access initiative before referring a patient for Medicare-subsidised allied mental health services.
This assessment session template structures the clinical content according to the GPMHSC Minimal Requirements MHTP template (May 2023), and is designed for use with MBS items 2700, 2701, 2715, 2717, 281 and 282. It synthesises information from NovoNote session recordings and NovoPsych psychometric data to allow GPs to complete the MHTP in a more expedited way.
Note: This document is not a referral letter, which must be provided (including a request for psychological treatment) to the allied health professional to ensure a valid referral.
GP Mental Health Treatment Plan (MHTP)
Patient Wellbeing Assessment
Reasons for Presenting
Describe the patient’s current mental health difficulties and what they are seeking from assessment and treatment, incorporating the patient’s own framing.
Patient History
Summarise relevant medical, mental health and social history, including prior diagnoses, treatment, living situation, relationships, employment and stressors.
Medications and Psychotropics
List current medications relevant to the patient’s mental health presentation, including dose and date of commencement or last change.
Results of the Mental State Examination
- Behaviour: Describe the patient’s activity level and any notable behaviours.
- Speech: Note pace of speech only if fast or slow.
- Mood: Record the patient’s self-described emotional state.
- Affect: Describe the range and appropriateness of the patient’s emotional response.
- Thoughts: Describe thought process and content, noting distortions or preoccupations.
- Perceptions: Note any reported hallucinations or sensory misinterpretations.
- Cognition: Describe memory, orientation, concentration and comprehension.
- Insight: Describe the patient’s understanding of their own condition.
- Judgment: Describe the patient’s decision-making ability and understanding of consequences.
Risk Assessment
Describe any identified risk of suicide, self-harm or harm to others, including ideation, intent and plan, or confirm risk was assessed and found absent.
Psychometric Assessment Results
State the name of the tool administered, date of administration, and results including scores and clinical classification.
Provisional Diagnosis of Mental Health Disorder
Describe the diagnostic impression based on DSM-5-TR and ICD-11 criteria, including rationale, relevant criteria met, supporting psychometric evidence, diagnostic code, and whether this is new or confirms a previous diagnosis.
Case Formulation
- Presenting factors:
- Predisposing factors:
- Precipitating factors:
- Perpetuating factors:
- Protective factors:
Setting Personal Recovery Goals
Describe what recovery looks like for the patient, prioritised goals, and strengths or supports to draw on.
Personal Management Plan
Repeat the below structure for each issue identified.
Issue: State the identified clinical issue in one sentence.
Goal: State a specific, functionally oriented goal based on session discussion.
Treatments and interventions: Describe planned psychological, pharmacological or other interventions, including patient actions.
Referrals: Describe any referrals to practitioners, services or programs discussed.
Intervention/Relapse-Prevention Plan
Describe the plan for relapse or crisis, including warning signs and support contacts discussed.
GP Mental Health Treatment Plan (MHTP)
Patient Wellbeing Assessment
Reasons for Presenting
Mary Blogs presented for review of her ongoing low mood and anxiety, which she described as “constant worry that won’t switch off” since separating from her partner four months ago. She is seeking support to manage her anxiety symptoms and improve her sleep so she can return to full work capacity. She has requested a referral for psychological treatment alongside her GP-led care.
Patient History
Mary is a 34-year-old woman with no significant past medical history and no prior psychiatric admissions. She has a history of a single depressive episode at age 26 following the end of a previous relationship, managed at the time with sertraline and six sessions of counselling, with full resolution of symptoms. She currently lives alone since her separation, works full-time as a primary school teacher, and describes reduced contact with friends over the past two months due to low motivation. She reports a supportive relationship with her sister, who lives locally and provides practical support.
Medications and Psychotropics
Sertraline 50mg daily, commenced by this practice three weeks ago.
Results of the Mental State Examination
- Mood: Described her mood as “flat and anxious most days”.
- Affect: Congruent with stated mood; range was somewhat restricted but reactive during discussion of her students.
- Thoughts: No evidence of thought disorder; preoccupied with worry about work performance and financial security.
- Cognition: Reported difficulty concentrating on lesson planning; oriented to time, place and person.
- Insight: Good insight into her current difficulties and their relationship to the recent separation.
Risk Assessment
Risk of suicide and self-harm was directly assessed and Mary denied any current or past suicidal ideation, intent or plan. No risk to others was identified.
Psychometric Assessment Results
K10 administered today: score 29, indicating a high level of psychological distress.
Provisional Diagnosis of Mental Health Disorder
Generalised Anxiety Disorder (DSM-5-TR 300.02) is the provisional diagnosis, based on excessive worry occurring more days than not for the past four months, associated with difficulty concentrating, sleep disturbance and restlessness, causing clinically significant impairment in occupational functioning. This is a new diagnosis, supported by an elevated K10 score.
Case Formulation
- Presenting factors: Excessive worry, low mood, sleep disturbance and reduced concentration over the past four months.
- Predisposing factors: Prior depressive episode in her mid-twenties; tendency towards perfectionism reported by Mary.
- Precipitating factors: Relationship separation four months ago.
- Perpetuating factors: Social withdrawal, reduced physical activity, ongoing financial stress.
- Protective factors: Stable employment, supportive sister, previous positive response to treatment, good insight.
Setting Personal Recovery Goals
Mary identified returning to her previous energy levels and confidence at work as her primary recovery goal, alongside re-establishing regular contact with friends. She noted her strong relationship with her sister and her long-standing commitment to her students as sources of motivation to engage in treatment.
Personal Management Plan
Issue 1
Issue: Generalised anxiety with excessive worry and sleep disturbance.
Goal: Reduce daily worry and improve sleep onset within 8 weeks, enabling full work capacity.
Treatments and interventions: Continue sertraline 50mg daily, reviewed by GP in 4 weeks; psychological treatment focused on cognitive behavioural therapy for anxiety.
Referrals: Referral to a clinical psychologist for CBT under a Better Access referral.
Issue 2
Issue: Low mood and social withdrawal.
Goal: Increase social engagement and pleasurable activity to at least twice weekly within 4 weeks.
Treatments and interventions: Behavioural activation strategies to be incorporated into psychological treatment; encouraged graded return to social contact with friends.
Referrals: No additional referral required; to be addressed within psychological treatment above.
Intervention/Relapse-Prevention Plan
Mary and her GP agreed she would contact the practice promptly if worry or low mood worsened significantly, sleep deteriorated further, or any suicidal thoughts emerged. Her sister is aware of her current difficulties and will check in weekly. Mary was provided with the practice’s after-hours contact details and information on Lifeline for out-of-hours support.
- Template Type
- Assessment Session
Author:
Dr Carla Smyth
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