Referral Form Social Work Services for GP Practices
Supports linkage and co-ordination of community psychosocial supports to compliment better patient outcomes.
Please read before completing:
•	This referral form can be completed by any member of GP Practice staff with consent of the patient.
•	Referral form can be submitted in handwritten or typed format, scanned or MS Word Document/PDF formats.
•	Provide attachments/supporting documentation as appropriate for any question and record ‘See Attachment’. 
•	Once completed please forward referral to referrals@ccnb.com.au or fax: 02 9979 7611
•	For further information please feel free to contact CCNB Health and Community Services Team 1300 002 262 
Inclusion Criteria	Y/ N/ NK	
The patient being referred consents to this referral being made		
The patient being referred has been recently hospitalised and is at risk of being without support		
The patient has chronic and/or complex health care conditions		
The patient does not have a mental health diagnosis of an acute, persistent and/or severe nature. 		
The patient lives in Willoughby, Lane Cove, North Sydney, Manly, Warringah, Pittwater and Mosman		

Referrers Details	
Name of Referrer: <<Doctor:Name>>	Date of Referral: <<Miscellaneous:Date>>	
Email: <<Doctor:E-mail>>	Landline: <<Practice:Phone>>	
GP Practice <<Practice:Name>>	Suburb<<Doctor:Postcode>>	
Best time and method to contact you if required?

	

How did you find out about us?

	With patient consent would you like feedback on activity and progress? 
How often?
What format/method is best?	
Declaration: The referrer agrees that all information included in this referral form is a full and accurate reflection of the support needs of the patient being referred based on your knowledge, experience and professional assessment of the individual and is necessary for CCNB to fulfil its duty of care to patients, staff and the community.	

Patient Details	
Patient Name	<<Patient Demographics:Full Name>>	Gender	<<Patient Demographics:Sex>>	
Medical Record No.		Date of Birth	<<Patient Demographics:DOB>>	
Address	<<Patient Demographics:Full Address>>	Suburb		
Landline	<<Patient Demographics:Phone (Home)>>	Mobile	<<Patient Demographics:Phone (Mobile)>>	
What the best time to contact?
		
How is it best to contact and communicate?		
Where’s the best place to meet?		
Does the patient have a substantive carer/family support?  Yes  No   Unknown 
Are they aware of this referral?  Yes  No   Unknown 
Can we contact them?   Yes  No   
Legal Guardian in place?  Yes     No  
Name and contact details:	
Income source:  Working  NewStart   Aged   Disability Pension   No income  Not known 	
Culturally and Linguistically Diverse? Yes  No NK 
Language(s):	Interpreter Required?  Yes  No  
	
First Australian or Torres Strait Islander Yes No  NK   	LGBTI Yes  No  Unknown   	
Family/Carer Details	Y/ N/ NK	
Does the patient have family or carers?		
Is the family or carer aware of the referral to the Social Work Programme?		
Name and contact details:	
Outline medical, health and social issues.	
<<Clinical Details:History List>>

	
Outline Other Co-existing issues (could include but is not limited to Drug and Alcohol/ Housing/Financial/Legal/Social and Vocational participation) the individual experiences.	

	
Are there any individual or environment risks we need to be aware of and assist in mitigating? 	
	
Are there other services involved?	
Service Name:
	Type of Services Provide:	Currently involved/history