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

REFERRED BY
Name: <<Doctor:Name>>
Practice: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Provider #: <<Doctor:Provider Number>>
HPI-I: <<Doctor:HPI-I>>
Email: <<Doctor:E-mail>>

	PATIENT DETAILS
Name: <<Patient Demographics:First Name>>
Gender: <<Patient Demographics:Gender>>
DOB: <<Patient Demographics:DOB>>
Address: 
<<Patient Demographics:Full Address>>
Postcode: 3212 <<Post code 3212?>>  3213 <<Post code 3213?>>  3214 <<Post code 3214?>> 3215 <<Post code 3215?>>
Home ph: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>
IHI: <<Patient Demographics:IHI>>
Medicare #: <<Patient Demographics:Medicare Number>>
Medicare expiry: <<Patient Demographics:Medicare Expiry Date>>
Pension:<<Patient Demographics:Pension Number>>
DVA #: <<Patient Demographics:DVA Number>>
Health Insurance:<<Patient Demographics:Health Insurance>>
ATSI: <<Patient Demographics:Ethnicity>>
Primary carer details: <<Patient Demographics:Next of Kin>>
Primary carer telephone: <<Patient Demographics:Next of Kin Phone>>
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 usual name of GP and 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 information?>>
Have you obtained informed consent for this referral from the guardian: <<Have you obtained consent for this referral ?>>

	

DETAILED HISTORY OF PRESENTING COMPLAINT
<<Detailed history of presenting complaint for triage>>

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
<<Clinical Details:History List>>	
PSYCHOSOCIAL HISTORY
<<Clinical Details:Social History>>
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 including date?>>	
MEDICATION (please ensure this is accurate)
<<Clinical Details:Medication List>>

ALLERGIES
<<Clinical Details:Allergies/Adverse 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:
<<Summary:Investigation Results (Selected)>>

Please include any reports that will assist with patient management

GP signature: ________________________________________________________________________