Referral Form
Referrer Information
If this is a self-referral, please disregard this section and skip to page 2
Name
First Name
Last Name
Relationship to person being referred:
Email
example@example.com
Phone Number
-
Area Code
Phone Number
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Referral Information
Is the person being referred from any of the following priority groups (please tick all that apply):
Aboriginal and/ or Torres Strait Islander
Older adult (over 65 years of age)
Child / young person (under 18 years of age)
Name of person being referred:
First Name
Last Name
Date of birth:
-
Day
-
Month
Year
Date
Contact details of the person being referred
If the person being referred is under 18 years of age or does not have the capacity to arrange an initial consultation, please provide the best contact details for the person's carer / guardian
E-mail address:
example@example.com
Phone Number:
-
Area Code
Phone Number
Legal guardian of person being referred (if applicable):
Carer of person being referred (if applicable):
Is the person being referred at risk of (please tick all that apply):
Causing physical harm to others
Causing physical harm to themselves
Does the person being referred have a mental or physical health diagnosis? If yes, please provide details:
Is the person being referred currently prescribed medication? If yes, please provide details:
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Reason for referral:
Please provide the primary reason for the referral; presenting symptoms; and relevant history
Goals:
Please provide a description of the goals that are hoped to be achieved by engaging with this service
Consent (please tick all that apply)
Self-referral
The person being referred has given consent for the referral to be made on their behalf
The person being referred is aware of all information outlined in this referral
The person being referred has given consent for the referrer to discuss this referral with At 1 Health (via phone, email or in person)
The person being referred agrees to be contacted directly by At 1 Health
Does the person being referred have any other support services involved? If yes, please provide details:
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