Referral Form – Better Health Network

To refer a patient to us, please fill out the below Referral Form.

Referral Details

Referrer Name*

Referrer Organisation*

Referrer Position*

Referrer Phone*

Referrer Email*

Referrer Fax*

Client Family Name*

Client Details

Client Given Names*

Client Date Of Birth (dd/mm/yyyy)*

Client Gender*

Client Home Address*

Client Contact Phone Number*

Client Country of Birth*

Is the client of Aboriginal or Torres Strait Islander origin?*

Does the client have a refugee status?*

Does the client require an interpreter?*

If yes, please state preferred language

Is the client living in insecure housing?*

Client Medicare Number* (Enter NA if not available)

Does the client have an active NDIS Plan?

Is the client seeking assistance to access the NDIS?

Please give details of the client's current GP (GP name, Practice name, Address, Phone)*

Does the client hold any of the following concession cards?*

Please select the type of service you’d like the client referred to:*

Please outline your reason for referral*

Please tick below if you have an Assessment and/or Care Plan and would be happy for BHN to contact you to obtain a copy. Alternatively, you can attach them below.

Assessment

Care Plan

Please attach an Assessment and/or a Care Plan if available

Max. file size: 100 MB.

Do you have any of the following:

Does the client give consent to a referral to BHN?