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

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

	PATIENT DETAILS
Name: Patient Demographics.Full Name
Gender: Patient Demographics.Gender
DOB: Patient Demographics.DOB
Address: Patient Demographics.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 Number
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 Fund Name
ATSI: Patient Demographics.ATSI Status
Primary carer details: Patient Demographics.NOK Name
Primary carer telephone: Patient Demographics.NOK Mobile 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: OT?
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 usual GP
If not, name of usual GP: If not name and prac
	SPECIAL ALERTS

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

		

DETAILED HISTORY OF PRESENTING COMPLAINT
Please provide detai

What questions do you want answered?
What questions do yo

What are the family's concerns?
What are the family'

RELEVANT PAST MEDICAL AND SURGICAL HISTORY
 Clinical Details.Past History	
PSYCHOSOCIAL HISTORY
Clinical Details.Social History
Is child in Out of Home Care? Is child in Out of H
Is child protection involved?   Is child protection 	
OTHER SERVICES INVOLVED
	
MEDICATION (please ensure this is accurate)
Clinical Details.Medications - Current Regular (with comments)

ALLERGIES
Clinical Details.Allergies	
HAVE ANY INVESTIGATIONS BEEN ORDERED TODAY?
Did you order any in	
TESTS ORDERED TODAY
Tests ordered today?	

	
RELEVANT RESULTS AND INVESTIGATIONS
 Clinical Details.Result List (Selected)
Please include any reports that will assist with patient management

GP signature: ________________________________________________________________________