Referral Form

If you are a health professional and would like to refer to us, please fill in this Referral Form.


    Referrer Details

    Referrer Name*

    Referrer Organisation*

    Referrer Position*

    Referrer Phone*

    Referrer Email*

    Referrer Fax



    Client Details

    Client Family Name*

    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)

    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 Star Health to contact you to obtain a copy. Alternatively, you can attach them below.
    AssessmentCare Plan
    Please attach an Assessment and/or a Care Plan if available

    Does the client give consent to a referral to Star Health?*

     

     
    Please prove you are human by selecting the Truck.