Client Referral Form - No 34 Aboriginal Health Service 
All infomation contained within this referal will be kept confidential 
Date of Referral: <<Patient Demographics:Referral Date>>
Title: <<Patient Demographics:Title>>
Surname: <<Patient Demographics:Surname>>
Given names: <<Patient Demographics:First Name>>
Date of Birth: <<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Full Address>>
Phone (home): <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Consent form signed: <<consent form signed >>	Reason For Referral: (explanations at base of form)
Care Coordinator: <<Care Coordinator referral?>>
Supplementary Services: <<Supplementary Services referral?>>
Health issues: <<Health issues?>>
Other reasons: <<Other reasons for referral?>>
Further infomation re referral (Medical info and primary diagnosis): <<Further info (Medical info and primary diagnosis)?>>	
Does the patient identify as:
Aboriginal? <<Does the Patinet identify as Aboriginal? >>
Torres Strait Islander? <<Does the Patinet identify as Torres Strait Islander?>>
Both Aboriginal and Torres Strait Islander? <<Does the Patinet identify as Aboriginal and TSI?>> 	Has the patient a current GP Management Plan or Team Care Arrangement? <<Has the patient a current GPMP or TCA?>>
(this is needed with the referral)	
Referrer Details:
Name of Referrer: <<Patient Demographics:Referral Doctor>>
Practice: <<Practice:Name>>
Address: <<Patient Demographics:Referral Doctor Address>>
Telephone: <<Practice:Phone>>
Mobile: <<Doctor:Phone>>
Email contact: <<Doctor:E-mail>>	Please indicate by selecting which of the following RISK factors this patient has: <<please select RISK factors this patient has:>>	
If client is under 18 years of age:
Guardian's Name: <<Guardians name >>
Contact number: <<Guardians number >>
Address: <<Guardians address>>		

Care Coordinator: can assist your Aboriginal and/or Torres Strait Islander patients to understand their diagnosis; understand and follow their care/management plan; arrange appointments for diagnostic tests, allied health professionals or specialists; connect with other community based services; assist patients to develop self management skills and adhere to medication and treatment regime.
Supplementary Services:   Funds can assist your Aboriginal and/or Torres Strait Islander patients with transport support to attend appointments; access of private specialists/health professional if public is not available, or waiting list is inappropriate for patient’s condition; payment of gap or full fee (where MBS rebate is not available) for specialist or allied health follow up care.