Forward completed Referral via Medical Objects to: Head to Health Gold Coast Referrals
 or Fax 07 3186 4099

By consenting to this referral, the person is consenting to the sharing of their personal information. The information contained in the referral is used by Head to Health phone service to: (1) deliver assessment and referral services, (2) for monitoring, aggregate reporting and evaluation purposes to improve quality and access to care. This information will be passed on to the recommended provider who will contact the person.

Please indicate the information in this form has been discussed with, and provided to, the patient.  Info discussed pt

Patient or Parent/Guardian/Carer consents to Referral Patient Consent

Referrer consents to the collection and storage of referrer details on internal database  Referrer's Consent

Referral Date  Miscellaneous.Date

REFERRER DETAILS

Referrer's role	Referrer's Role	
Referrer's name	Treating Doctor.Name	
Referrer's email	Treating Doctor.E-mail	
Practice name	Practice.Name	
Practice address	Practice.Address	
Practice phone no	Practice.Phone	
Practice fax no	Practice.Fax	

PATIENT DETAILS

RE: Patient Demographics.Full Name	DOB: Patient Demographics.DOB	
Gender  Patient Demographics.Gender	Other gender identity (if applicable)  Other Gender	
Address: Patient Demographics.Address	Experiencing homelessness Homelessness	
Home phone: Patient Demographics.Phone (Home)	Mobile phone: Patient Demographics.Phone (Mobile)	
	Health Care/Pension Card  Health Care/Pension
Expiry date: Expiry date	
Aboriginal &/or Torres Strait Islander status  A&TSI	Culturally or Linguistically Diverse (CALD)  CALD
Language spoken at home  Language
Is an interpreter required  Interpreter	
Is there a current Mental Health Treatment Plan in place  MH Treatment Plan
Emergency contact name  EC Name	Emergency contact's relationship to person EC Relationship	
Emergency contact's phone number  EC Phone	Emergency contact's role  EC's Role	

REFERRAL NOTES

Mental health diagnosis
MH Diagnosis
Medications 

Clinical Details.Medications - Current Regular	

KEY GOALS (What else do we need to know to support the individual moving forward)

What are the individual's key goals and hopes for engaging in the program?  Key goals

What are the individual's strengths and support systems?  Strengths

Is there anything you or the individual would like us to know about how we can best meet their needs, e.g. cultural needs; medical; medication issues; developmental, functional; living skills; social; emotional; trauma, abuse and neglect; etc?  Any other

IDENTIFIED AREAS OF SUPPORT REQUIRED

Emotional Wellbeing:  Emotional Wellbeing

Physical Health/ADLs:  Physical Health

Social Connection:  Social Connection

Food, Diet or Lifestyle:  Food, Diet

Housing or Social Supports:  Housing

Financial Needs & Benefits:  Financial

Families & Relationships:  Families

Employment & Education:  Employment

Domestic Violence:  Domestic

NDIS & My Aged Care:  NDIS

SAFETY ALERTS - Are there any risk factors we should be aware of when visiting the home/client, e.g. history of aggressive behaviour?  Safety Alerts
If yes, please specify: Specify

Risk of harm to self:  Risk of harm to self

Risk of harm to others:  Harm to others

Mental Health Order:  Mental Health Order

Enduring Power of Attorney:  Enduring Power

Not able to make own decision/Guardianship:  Guardianship

Orders relating to children:  Orders

Intervention Order/AVO:  Intervention

Triggers/Trauma:  Triggers

Current treatment plans: Plans/History

Medical History

Clinical Details.Problem List (Current) With Comments

Clinical Details.Problem List (Resolved) With Comments

Plus Social Clinical Care Coordination is a comprehensive, high intensity clinical support service for people age 18+ who experience the impact of severe mental illness and are not currently case-managed or accessing Gold Coast Health mental health services. Up to 26 weeks clinical care coordination and wellbeing program that is structured, recovery and goal orientated focused on creating significant improvements in quality of life, health and wellbeing.