Referral Form - for GP use only

General Practitioners Details

GP Name^*

GP/Practice Email

GP Practice Name^*

Client Details

Date of referral

First Name^*

Surname^*

Address

Suburb

State

Postcode

Country

Phone^*

Carer's name

Carer's phone

DOB^*

Gender

Aboriginal or Torres Strait Islander

Country of birth

Main language spoken at home

Is an interpreter needed?

Culturally or Linguistically Diverse background

Smoker or ex smoker

Does the Client have a current GP Plan

Does the client have a current healthcare card

If eligible, has client exhausted their MBS funded allied health services under a GPMP or TCA

Medical History

Please indicate which condition(s) the client has been diagnosed with (client requires at least one to be eligible) ^*

Obesity
Diabetes
Osteoarthritis
Chronic Respiratory Disease

At risk of obesity (youth)
Chronic pain
Frailty
Physical inactivity

Other Relevant Medical History

Referral - Service Type and Location

Please note referrals to this program can only be made to locations and Allied Health Disciplines where listed in the WARATAH GP information pack

Service^*

Location^*

Preferred Business

Preferred Allied Health Practitioner

Health Linker

Have you identified additional complexities and/or social circumstances getting in the way of a person being able to prioritise and work towards achieving their health care goals?^*

Relevant attachments(e.g. GPMP)

Choose file

Consent for referral provided by client^*

Yes

* Required fields

General Practitioners Details

GP Name*

GP/Practice Email

GP Practice Name*

Client Details

Date of referral

First Name*

Surname*

Address

Suburb

State

Postcode

Country

Phone*

Carer's name

Carer's phone

DOB*

Gender

Aboriginal or Torres Strait Islander

Country of birth

Main language spoken at home

Other langauge,please specify

Is an interpreter needed?

Preferred language including sign language, required communication devices or special interpreter needs

Culturally or Linguistically Diverse background

Smoker or ex smoker

Does the Client have a current GP Plan

Does the client have a current healthcare card

If eligible, has client exhausted their MBS funded allied health services under a GPMP or TCA

Medical History

Please indicate which condition(s) the client has been diagnosed with (client requires at least one to be eligible) *

Other Relevant Medical History

Referral - Service Type and Location

Please note referrals to this program can only be made to locations and Allied Health Disciplines where listed in the WARATAH GP information pack

Service*

Location*

Preferred Business

Preferred Allied Health Practitioner

Health Linker

Have you identified additional complexities and/or social circumstances getting in the way of a person being able to prioritise and work towards achieving their health care goals?*

If yes would you also like your patient to be connected to a WARATAH Health Linker? If yes, please let them know you have indicated this as part of the referral and that they can expect a call from the Health Linker within the next 7 days.*

Additional information to support Health Linker

Relevant attachments(e.g. GPMP)

Consent for referral provided by client*

GP Name^*

GP Practice Name^*

First Name^*

Surname^*

Phone^*

DOB^*

Please indicate which condition(s) the client has been diagnosed with (client requires at least one to be eligible) ^*

Service^*

Location^*

Have you identified additional complexities and/or social circumstances getting in the way of a person being able to prioritise and work towards achieving their health care goals?^*

If yes would you also like your patient to be connected to a WARATAH Health Linker? If yes, please let them know you have indicated this as part of the referral and that they can expect a call from the Health Linker within the next 7 days.^*

Consent for referral provided by client^*