Barwon Health North Child & Family Service Referral T 1300 715 673 F 4215 7795
E-Refer using ReferralNet
Referral date: <FormattedDate>	Version 1
(10/2020)	

REFERRED BY
Name: <DrName>
Practice: <Practice>
Address: <UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Provider #: <DrProviderNo>
HPI-I:<PracticeHPIO>
Email:  <DrEmail>

	PATIENT DETAILS
Name: <PtFullName>
Gender: <PtSex>
DOB: <PtDoB>
Address: <PtAddress>
Postcode: 3212<Post code 3212>  3213<Post code 3213>  3214<Post code 3214>  3215<Post code 3215>
Home ph: <PtPhoneH>
Mobile: <PtPhoneMob>
Email:<PtEmail>
IHI:<PtIHI>
Medicare #: <PtMCNo>
Medicare expiry: <PtMCExpiry>
Pension:<PtPensionNo>
DVA #: <PtDVANo><PtDVACard>
Health Insurance:<PtInsFund>
ATSI: <PtEthnicity>
Primary carer details:<NOKName>
Primary carer telephone:<NOKContact>
Interpreter required: <Interpreter required?>
Language: <Language?>	
SPECIALTY SERVICE REQUESTED - THIS SECTION MUST BE COMPLETED
Patient needs to reside in postcode 3212/3213/3214/3215 (Northern Suburbs Geelong)
This is a child development service for children with developmental concerns from birth to pre-school (ie not yet attending school). Will not accept medical referrals.

Speech Therapist:  <Speech therapist>
Physiotherapist:  <Physiotherapist>
OT:  <Occupational Therapist>
Psychologist:  <Psychologist>
Dietitian:  <Dietitian>
Social Worker:  <Social Worker>
Child Psychiatrist: (GP referral needed):  <Child Psychiatrist>
Paediatrician: (GP referral needed):  <Paediatrician>

 Referrals are reviewed by our intake worker for allocation to the appropriate team member
		
REFERRAL DETAILS
Are you the patient's usual GP:  <Are you the patient's usual GP?>
If not, name of usual GP:  <If not, provide name of Usual GP & Practice>
	SPECIAL ALERTS

	
PATIENT CONSENT
Patient consents to attend MBS bulk billed clinic if available: <Patient consents to MBS bulk billed clinic if avail>
If yes, do you wish this to be a 12 month referral? <If yes, do you wish this to be a 12 month referral>
Patient consents to sharing medical information: <Patient consents to sharing of medical information>
Have you obtained informed consent for this referral from the guardian: <Have you obtained consent for this referral from the guardian>

	

DETAILED HISTORY OF PRESENTING COMPLAINT
<Please provide detailed description for triage>

PROVISIONAL DIAGNOSIS
What questions do you want answered?
<What questions do you want answered?>
What are the family's concerns?
<What are the family's concerns?>
	
RELEVANT PAST MEDICAL AND SURGICAL HISTORY
<PMHAll>	
PSYCHOSOCIAL HISTORY
<SocialHx>
Is child in Out of Home Care?  <Is child in Out of Home care?>
Is child protection involved?   <Is child protection involved?>	
OTHER SERVICES INVOLVED
<Referrals to other services eg; allied health (include date)>	
MEDICATION (please ensure this is accurate)
<CurrentRx>

ALLERGIES
<Reactions>	
HAVE ANY INVESTIGATIONS BEEN ORDERED TODAY?
<Did you order any investigations today?>	
TESTS ORDERED TODAY
<List any tests ordered today>	

	
RELEVANT RESULTS AND INVESTIGATIONS
<Ix>
Please include any reports that will assist with patient management

GP signature: ________________________________________________________________________