Client Referral

Referrer

Referral made by*

Referrer Organisation Name*

Referrer Contact*

First Last

Referrer Phone*

Referrer Email*

Reason for Referral

Reason for client referral*

Client

Client consents to referral

Client consents to referral

Client Name*

First Last

Client Address*

Street Address City State Post Code

Client Phone*

Client Date of Birth*

DD

MM

YYYY

Client Gender*

Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Phone*

Relationship to Client*

Chronic Care (ITC) Program

For 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

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 Programs

What 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 apply

Expand on services currently being accessed*

Upload supporting documents*

Drop files here or

Client GP

GP Name*

First Last

GP Practice Name*

GP Phone*

Assign Regular GP

Presenting problem*

Medical history*

Upload client files*

Drop files here or

Other

Expand on presenting problem*

Upload supporting documents*

Drop files here or

Please check this box