Under Better Access you must give the referring practitioner a written report on completion of each course of treatment, covering the assessments you carried out, the treatment you provided, and your recommendations on future management. The report is a condition of the MBS item, and the first falls due after the initial course of up to six sessions.
What exactly does Medicare require you to send?
The requirement is written into the item descriptor, not buried in guidance. Item 80010, the 50-minute individual psychological therapy item for eligible clinical psychologists, is payable only if, among other conditions, "on the completion of the course of treatment, the eligible clinical psychologist gives a written report to the referring practitioner on assessments carried out, treatment provided and recommendations on future management of the patient's condition".
The wording is identical for focussed psychological strategies. Item 80110 applies the same clause to eligible registered psychologists, and the parallel items apply it to eligible social workers and occupational therapists. So this is not a clinical-psychology quirk. If you bill a Better Access treatment item, the report is part of what you were paid to do.
Three content headings, then, and only three. Everything else is your discretion, which matters more than it sounds once you get to what to leave out.
When is the report actually due?
Not "after six sessions". After each course of treatment, which is a different thing.
Explanatory note MN.6.2 sets the limits: an initial course of treatment is a maximum of six services, and a subsequent course is a maximum of six more up to the patient's cap of ten individual services per calendar year. The referring practitioner decides how many services the patient gets within those limits, so a referral for four sessions creates a four-session course, and the report falls due at the end of it.
Two consequences practices miss. First, if the client finishes early or stops coming, the course is still complete and the report is still owed. Second, the obligation repeats: MN.6.2 states that "a written report must also be provided to the referring practitioner at the completion of any subsequent course(s) of treatment provided to the patient". MN.7.4 says the same for focussed psychological strategies providers. One report per course, every course.
Write it while the final session is fresh. The GP needs it before they review the mental health treatment plan and decide whether to write a further referral, so a report that lands three weeks later has missed the decision it exists to inform.
What goes in the letter, section by section?
A workable structure maps onto the three required headings and adds only the scaffolding a busy GP needs to read it in ninety seconds.
- Identifying block. Client name, date of birth, your name and provider number, the referral date, the dates of the first and last sessions, and the number of services delivered.
- Reason for referral. One or two lines restating what the GP asked for. It anchors the rest and shows you worked to the referral.
- Assessments carried out. Named measures with dates and scores, plus the clinical picture at intake. This is where your intake assessment earns its keep.
- Treatment provided. Modality, session count, focus of the work, and adherence. Two or three sentences, not a session-by-session log.
- Outcome. Repeat measures with the change between them. A GP can act on "DASS-21 depression 24 to 12" in a way they cannot act on "good progress".
- Recommendations on future management. The part the GP most needs: whether you recommend a subsequent course, how many sessions, what else you suggest (review of medication, sleep, exercise, referral elsewhere), and any risk issues that need their attention.
- Sign-off. Your name, registration and endorsement, and how to reach you.
Keep it to one page. Where you have a shared treatment plan with goals already written down, the outcome and recommendation sections write themselves from it.
What should you leave out?
This is the discipline that separates a good report from a risky one. The MBS asks for assessments, treatment and recommendations. It does not ask for the content of sessions, and the client did not consent to a narrative account of their life reaching their GP's file.
Leave out session-by-session detail, verbatim disclosures, third-party information about partners or family members, the client's speculation about others, and anything you recorded as a working hypothesis you have since dropped. Where a disclosure is genuinely clinically necessary for the GP to manage care, include the minimum that makes the point rather than the story that produced it.
The reasoning here is the same necessity test that governs any release of health information, covered in more depth in our guide to when a psychologist can break confidentiality. Under APP 6, health information is sensitive information, and the fact that a disclosure is permitted does not make every level of detail within it appropriate.
A practical test before you send: if the client read this letter, would anything in it surprise them?
What does a good report look like?
This is a fictional example, written to show length and register rather than to be copied.
Re: Jordan Miles, DOB 14/03/1991. Referral received 2 February 2026 under a Mental Health Treatment Plan. Six sessions, from 11 February to 8 April 2026.
- Reason for referral: Assessment and treatment of low mood and worry affecting work performance.
- Assessments carried out: Clinical interview at session one, with the DASS-21 administered at sessions one and six. Initial scores were in the moderate range for depression and the severe range for anxiety, with a presentation consistent with generalised anxiety and secondary low mood. No suicidal ideation at intake or review.
- Treatment provided: Six individual sessions of cognitive behaviour therapy, focused on cognitive restructuring, graded exposure to avoided work situations, and sleep and activity scheduling. Attendance and between-session practice were consistent.
- Outcome: DASS-21 anxiety reduced from the severe to the mild range and depression from moderate to mild. Jordan has returned to chairing team meetings, an activity avoided at intake.
- Recommendations on future management: I recommend a subsequent course of four sessions to consolidate gains and complete relapse prevention. A review of sleep at your end may be useful. No current risk concerns.
Note what it does not contain: no session narrative, no family detail, no diagnosis stated more firmly than the assessment supports.
Does the client need to consent to the report?
Tell the client at the start, not at the end. A Better Access referral is a shared-care arrangement and the report back is part of it, so the cleanest position is that your informed consent and collection notice names the report explicitly: who receives it, roughly what it covers, and when it is sent.
That removes the awkward conversation in session six, and gives you a documented basis for the disclosure rather than an assumption about what the client expected. Section 3.3 of the shared Code of conduct adopted by the Psychology Board treats seeking informed consent before disclosing information, and documenting it where possible, as good practice.
Offering to read the report with the client is optional but often worth five minutes. It catches factual errors, and clients who know what their GP has been told tend to use the GP more openly.
Which referral and record rules trip practices up?
Three, repeatedly.
The referral must be in hand at the first session. MN.6.2 states the provider "must be in receipt of the referral at the first mental health consultation". Starting on a promise that the plan is coming is a billing problem, not an administrative one.
Keep the referral for two years. The same note requires you to retain the referral for two years from the date the first treatment service was rendered. That sits alongside, not instead of, the longer clinical record retention periods.
A plan does not expire, a referral runs out. Per the Better Access explanatory note, a Mental Health Treatment Plan does not expire and a new one should not be created unless exceptional circumstances exist. What the client needs for sessions seven to ten is a review and a new referral, not a new plan. Telling clients to "get a new mental health plan" sends them for the wrong appointment.
Note too that the same explanatory note asks all Better Access providers to keep adequate and contemporaneous records, and that only clinical details recorded at the time of attendance count towards the consultation time. A report written afterwards is not part of the session you billed.
How do you make this a five-minute job?
The report is only slow when the information is scattered. If intake scores sit in a PDF, outcome measures in a spreadsheet and session focus in free text, every report becomes an archaeology exercise, which is why they get written late.
The fix is structural: administer measures inside the record, tag the referral with its session allocation so the system tells you when a course is complete, and keep goals in one place so recommendations write themselves. PractaLuma is AI-native practice management software for Australian mental-health practices, and the clinical notes and client records modules are built so the report to the GP is assembled from what you have already recorded rather than composed from scratch. Pricing is on the pricing page.
Frequently asked questions
Do I have to send a report if the client only attended twice? Yes. The obligation attaches to completion of the course of treatment, not to a session count. If the client disengages, write a short report covering what was assessed, what was provided and what you recommend, and note the non-attendance.
Can I send the report by email? Only over a channel appropriate for health information, and with the client informed of it. Secure messaging into the GP's clinical software is the safer default. If you use email, address it to the practice's secure address rather than a personal one.
What if the referral came from a psychiatrist or paediatrician rather than a GP? The report goes to the referring practitioner, whoever that is. Direct referrals from psychiatrists and paediatricians are eligible referral sources under Better Access, and the reporting condition in the item descriptor applies the same way.
Is this different from writing a referral letter myself? Yes. A report back closes a loop the GP opened, so it is written to their question. If you are writing to send a client on to someone new, see our guide to referral letters.
This article is general information about MBS requirements, not legal or billing advice. Check current item descriptors on MBS Online before relying on any figure or condition, as items change.