CountryCare Connect Hubs

CountryCare Connect Hubs

Mental Health Multidisciplinary Teams Project - Expression of Interest Form
The Darling Downs and West Moreton PHN (the PHN) invites Expressions of Interest from eligible GP practices – either individual practices or partnerships to establish, operate and deliver a CountryCare Connect Hub across the nominated underserviced Local Government Areas (LGAs) in the region.

This commissioned initiative aims to strengthen access to primary-based mental health care for people with severe and/or complex mental health needs, particularly in rural communities experiencing high levels of unmet need, workforce shortages, and fragmented service pathways.

Update: The closing date for expressions of interest has been extended to Monday, 22 December 2025 at 2pm.

Questions regarding the EOI process must be submitted to Practice Support by close of business, Thursday 11 December. To ensure a transparent application process, all questions will be listed anonymously with the corresponding answers and shared weekly via the CountryCare Connect webpage.

For further context regarding the opportunity and eligibility requirements, please refer to the Grant Guidelines.

For insights into the service model and key components, funding mechanism, and roles, refer to the Service Overview.
Practice name:*
Practice address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice contact name:*

First NameLast Name
Practice contact phone:*
Please enter a valid phone number.
Practice contact email: *
example@example.com
GP Lead name:*

First NameLast Name
GP Lead phone:*
Please enter a valid phone number.
GP Lead email: *
example@example.com
Entity name:*
Entity ABN:*
Entity address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Entity authorised signatory: *

First NameLast Name
Entity authorised email:*
example@example.com

15. Please review the Grant Guidelines provided. I/we have read and understood the guidelines for this grant.*

YesNo
Grant Guidelines
16. Acknowledgement, capacity and ability to comply with the PHN's Service Agreement Terms and Conditions. I/we acknowledge the PHN Service Agreement Terms and Conditions.*

YesNo
PHN Service Agreement Terms and Conditions
17. Please attach evidence that the organisation is financially viable, such as last year's financial statements, audited if available, or provide other information as may be requested by the PHN. *

Cancelof
18. Do you have any actual, potential or perceived business or personal conflicts of interest to declare? If yes, please provide details in the section below.*

YesNo
What type of conflict?

BusinessPersonalOther
Please provide details of this conflict of interest.
Declaration

This declaration should be completed AFTER completing the online submission, it must be completed by a person identified in your organisation’s constitution, or holding a position that is identified as being authorised to commit your organisation to the conditions as described in any contract or Funding Agreement with the PHN.

I acknowledge and certify that:
- The organisation has read and understood the Grant Guidelines
- The information in this document is true and correct
- None of the organisation’s office bearers, employees or agents have been charged or convicted of committing a criminal offence which will reasonably affect the ability of the organisation to undertake a future service delivery.
Consent to release information

The PHN collects information from applicants during this grant process. The PHN is requesting this information from you so that it can be shared with the grant selection panel for evaluation and selection.

The Australian Privacy Principles and the Privacy Act 1988 (Cth) prohibit us from releasing this information without your consent. Further, the PHN has a Privacy Policy that is available on request. The policy provides guidelines on the collection, use, disclosure and security of your information. The Privacy Policy contains information on how you may request access to and correction of, your personal information and how you may complain about a breach of your privacy and we will deal with such a complaint. The PHN will not disclose your personal information to anybody else unless we are required to do so by law.

I acknowledge and certify that:
- I understand that it is my choice as to what information I provide.
- I understand that I am not obliged to provide any information requested of me, but that my failure to do so will result in the PHN being unable to provide my details for the purposes outlined above.
- I have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure.
PERSON MAKING THE GRANT DECLARATION

I acknowledge that by lodging this grant application with the PHN I am providing an electronic signature for this Declaration.
Name:

First NameLast Name
Signature:

Clear
Title:
Date of application:

MonthDayYear
Date
Should be Empty: