Head To Health
Referral Form

Servicing people in the Brisbane South PHN catchment area. Head to Health Phone Service provides a free, confidential referral service for anyone seeking help for their wellbeing or wanting support for a patient or someone they care about. 

If the person has acute mental health needs, refer to MH Call on 1300 64 22 55

Fax: 07 30894060 
Medical Objects ID: TH4114000UG

Referral date: <TodaysDate>
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REFERRING DOCTOR DETAILS
Name: <DrName>
Practice Name: <Practice>
Address: <DrAddress>
Phone: <DrPhone>
Email: <DrEmail>
Fax: <DrFax>

Any other practitioner involved in care of the patient: <Any other practitioner involved in care of the patient>
Patient's usual GP (if different from referrer): <Patient's usual GP (if different from referrer):>

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PATIENT DETAILS
RE: <PtFirstName> <PtSurname>		DOB: <PtDoB>
Preferred Name: <PtPrefName>
Pronouns: <Pronouns>
Gender: <PtSex>
Address:<PtStreet>, <PtCity>, <PtState> <PtPostcode> 
Postcode: <PtPostcode>
Mobile Phone:<PtPhoneMob>
Email: <PtEmail>
Preferred Language:  <Patient's preferred language>
Interpreter required: <Is an interpreter required>

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REFERRAL SUPPORT PERSON
Parent/caregiver name: <Parent/caregiver name (if applicable)>
Parent/caregiver relationship to patient: <Parent/Caregiver relationship to patient (If Applicable)>
Parent/caregiver contact details:  <Parent/caregiver contact details (if applicable)> 

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CONSENT TO SHARE INFORMATION 

The Privacy Act requires that the consumer sign this form to provide consent for the release of their information. By signing below, the consumer gives consent for Head to Health Phone Service to seek and share information concerning matters related to this application, with the Brisbane South PHN, the referral support person outlined in this form, and other service providers relevant to this referral. The consumer also gives consent to their information being used for statistical and evaluation purposes to improve mental health services in Australia. They understand that this will include details about them such as date of birth, gender and types of services they use, but will not include their name, address or Medicare/Pension/Health Care Card numbers

Verbal Consent Given <Verbal consent given?>   <TodaysDate>

VERIFICATION
Electronically Signed: <DrName>
<DayAndDate>\

Referral Notes 
<Referral Notes>

Phone 1800 595 212 | Fax 07 30894060 | bs.headtohealth.iar@neaminational.org.au