Client Referral Form - No 34 Aboriginal Health Service 
All infomation contained within this referal will be kept confidential 

Date of Referral: <TodaysDate>
Title: <PtTitle>
Surname: <PtSurname>
Given names: <PtFirstName>
Date of Birth: <PtDoB>
Gender: <PtSex>
Address: <PtAddress>
Phone (home): <PtPhoneH>
Mobile: <PtPhoneMob>
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 infomation and primary diagnosis): <Further infomation re referral (medical infomation and primary diagnosis)?>	
Does the patient identify as:
Aboriginal? <Are you Aboriginal?>
Torres Strait Islander? <Are you Torres Strait Islander?>
Both Aboriginal and Torres Strait Islander? <Both Aboriginal and Torres Strait Islander?>
	Has the patient a current GP Management Plan or Team Care Arrangement? <Has the patient a current GP Managment Plan or Team Care Arrangement?>
(this is needed with the referral)	
Referrer Details: 
Name of Referrer: <DrDetails>
Practice: <Practice>
Address: <UsrAddress>
Telephone: <UsrPhone>
Mobile: <DrMobilePhone>
Email contact: <DrEmail>	Please indicate by selecting which of the following RISK factors this patient has: 
<Please indicate by selecting which of the following RISK factors this patient has?>
	
If client is under 18 years of age:
Guardian's Name: <Guardian's Name?>
Contact number: <Guardians contact number?>
Address: <Guardian's 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.