Client Referral Gurayi-Biyn Yadha You Mob Are Well ITC Chronic DiseaseReferral Yadhaba Wellbeing Services YadhabaReferral Dhanggan Gudjagang Mother & Baby Dhanggan GudjagangReferral Buridjga Youth Services Buridjga YouthReferral ReferrerReferral made by*GP ServiceCCLHD/NunyaraAboriginal Hospital Liaison OfficerGovernment AgencyCommunity ServicesOther - please specifyOther Referrer Referrer Organisation Name* Referrer Contact* First Last Referrer Phone*Referrer Email* Reason for ReferralReason for client referral*Access Chronic Care (ITC) ProgramOther - specifyOther reason for referral ClientClient consents to referral Client consents to referral Client Name* First Last Client Address* Street Address City ACTNSWNTQLDSATASVICWA State Post Code Client Phone*Client Date of Birth* Day Month Year Client Gender*MaleFemaleNeutralTransgenderEmergency ContactEmergency Contact Name* First Last Emergency Contact Phone*Relationship to Client* Chronic Care (ITC) ProgramFor referral to the ITC Program the client must be Aboriginal and / or Torres Strait Islander and have at least 1 of the chronic conditions listed below. Priority is given to clients who are having difficulty accessing health services due to a lack of transport or financial constraints.Which chronic condition/s does the client have?* Diabetes Chronic Respiratory Disease Cancer Cardiovascular Disease Chronic Kidney Disease What care assistance does the client require?* Care Coordination Supplementary - Transport Support Supplementary - Specialist Support Supplementary - Allied Health Support Supplementary - Medical Aid Support Supplementary - Nutritional Supplements Is the client registered for Closing The Gap (CTG)?* Yes No Unsure Has the client had a 715 Aboriginal and Torres Strait Islander Health Check in the last 12 months?* Yes No Unsure Other relevant information including client barriers to accessing health services and associated health risks:*Attach supporting documents eg. Care Plan, Aboriginal and Torres Strait Islander Health Check, Hospital Discharge Summaries* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 50 MB, Max. files: 3. A current GP Care Plan must be attached and uploaded with this referral form. Alternatively you can print this completed referral form and fax it together with the current GP Care Plan to the Yerin ITC Coordinator on (02) 4351 1037.Yerin ProgramsWhat problems are currently being experienced?* Mental health Gambling issues Parenting issues Alcoholism Drug Addiction Financial issues Housing issues Racism Other Please tick all that apply.Expand on concerns including relevant history*Are any of the service below currently being accessed?* Mental Health Services Drug & Alcohol Services Family Support Services Gambling Support Services Financial Counseling Services Other Services Please tick all that applyExpand on services currently being accessed*Upload supporting documents* Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 50 MB, Max. files: 6. Client GPGP Name* First Last GP Practice Name* GP Phone*Assign Regular GPPresenting problem*Medical history*Upload client files* Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 50 MB, Max. files: 6. OtherExpand on presenting problem*Upload supporting documents* Drop files here or Select files Accepted file types: doc, docx, pdf, jpg, jpeg, png, Max. file size: 50 MB, Max. files: 6. Please check this box
ReferrerReferral made by*GP ServiceCCLHD/NunyaraAboriginal Hospital Liaison OfficerGovernment AgencyCommunity ServicesOther - please specifyOther Referrer Referrer Organisation Name* Referrer Contact* First Last Referrer Phone*Referrer Email* Reason for ReferralReason for client referral*Access Chronic Care (ITC) ProgramOther - specifyOther reason for referral ClientClient consents to referral Client consents to referral Client Name* First Last Client Address* Street Address City ACTNSWNTQLDSATASVICWA State Post Code Client Phone*Client Date of Birth* Day Month Year Client Gender*MaleFemaleNeutralTransgenderEmergency ContactEmergency Contact Name* First Last Emergency Contact Phone*Relationship to Client* Chronic Care (ITC) ProgramFor referral to the ITC Program the client must be Aboriginal and / or Torres Strait Islander and have at least 1 of the chronic conditions listed below. Priority is given to clients who are having difficulty accessing health services due to a lack of transport or financial constraints.Which chronic condition/s does the client have?* Diabetes Chronic Respiratory Disease Cancer Cardiovascular Disease Chronic Kidney Disease What care assistance does the client require?* Care Coordination Supplementary - Transport Support Supplementary - Specialist Support Supplementary - Allied Health Support Supplementary - Medical Aid Support Supplementary - Nutritional Supplements Is the client registered for Closing The Gap (CTG)?* Yes No Unsure Has the client had a 715 Aboriginal and Torres Strait Islander Health Check in the last 12 months?* Yes No Unsure Other relevant information including client barriers to accessing health services and associated health risks:*Attach supporting documents eg. Care Plan, Aboriginal and Torres Strait Islander Health Check, Hospital Discharge Summaries* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 50 MB, Max. files: 3. A current GP Care Plan must be attached and uploaded with this referral form. Alternatively you can print this completed referral form and fax it together with the current GP Care Plan to the Yerin ITC Coordinator on (02) 4351 1037.Yerin ProgramsWhat problems are currently being experienced?* Mental health Gambling issues Parenting issues Alcoholism Drug Addiction Financial issues Housing issues Racism Other Please tick all that apply.Expand on concerns including relevant history*Are any of the service below currently being accessed?* Mental Health Services Drug & Alcohol Services Family Support Services Gambling Support Services Financial Counseling Services Other Services Please tick all that applyExpand on services currently being accessed*Upload supporting documents* Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 50 MB, Max. files: 6. Client GPGP Name* First Last GP Practice Name* GP Phone*Assign Regular GPPresenting problem*Medical history*Upload client files* Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 50 MB, Max. files: 6. OtherExpand on presenting problem*Upload supporting documents* Drop files here or Select files Accepted file types: doc, docx, pdf, jpg, jpeg, png, Max. file size: 50 MB, Max. files: 6. Please check this box
