Community Health & Wellbeing Referral Form

Please complete the below personal, demographic and referral details

(if unsure of any details at the time of completing the form please type unknown).

To send the referral, click SUBMIT REFERRAL button.

Our intake team will determine the eligibility for Community Health & Wellbeing services

and will contact the client in the near future via telephone to continue processing this referral.

If you have any queries regarding this form please contact:

NCN Health - Community Health and Wellbeing Centralised Intake Team on (03) 5871 0944

Referrer Details:

Person completing this form: *

Name of the person completing this form: *

Contact Telephone Number for person completing form *

(HEALTH PROFESSIONAL USE ONLY) What health service do you work for?

Do you have consent to complete this form for the client? *

Yes, the client has given verbal consent for this form to be submittedN/A, I am completing this referral form for myselfYes, I am the parent, guardian or carer for this client (under 16 years of age) and I give consent for this form to be submitted

Client Personal & Demographic Details:

First Name: *

Last Name: *

Contact Phone Number: *

Email address:

Gender: *

Sex at Birth: *

Different term (please specify):

Date of Birth: *

Home Address: *

Aboriginal and/or Torres Strait Islander origin? *

Country of Birth: *

Interpreter Required? *

Preferred Language: *

Name of Emergency Contact Person? (Parent/Guardian for those under 16 years of age) *

Emergency Contact Persons Contact Phone Number *

Emergency Contact Persons relationship to you? *

Current GP/ Medical Clinic? *

Medicare Number: *

Pension, Health Care Card or DVA Card? *

Concession/ DVA Card Number:

Occupation:

Living Arrangements: *

Consent to send SMS appointment reminders? *

Consent to receive emailed correspondence? *

Service(s) Requested:

Reason for Referral? *

Medical History: *

Current Medications: *

NDIS Participants - Do you require any of the following High intensity supports?

Allergies: *

Referral Funding/Packages Information:

If YES, please advise of Service Providers name (e.g. MHA Care or Connextions)

Further Relevant Information:

Other Relevant Information:

Upload/attach any relevant medical documents or results (if none please ignore and move to submit)

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Date of Referral Form: *

Click the SUBMIT REFERRAL button below

to send this referral to our Intake Team

Our intake team will contact the client in the near future via telephone to determine eligibility and continue processing this referral.

Please note the incoming telephone call will display as an unknown telephone number.

Our team will leave a voicemail if unable to talk to you directly.

If you have any queries or require further information please contact:

NCN Health - Community Health & Wellbeing Centralised Intake Team

(03) 5871 0944

Privacy: Please refer to NCN Health privacy information regarding the use of personal information

https://ncnhealth.org.au/privacy/