Referral Form 
Fax to: (07) 3172 5851
<TodaysDate>	

Services requested  	
o Psychologist	o Dietitian	o Exercise Physiology 	
o Multidisciplinary Health Transformation Program	
Health professionals at the Centre for Integrative Health will provide a summary of patient treatment and recommendations throughout their care.	
Referrers Details 	
Name	<DrName>	Provider Number	<DrProviderNo>	
Phone	<DrPhone>	Fax	<DrFax>	
Address	<DrAddress>	
Client Details 	
Name	<PtFullName>	Medicare Number	<PtMCNo>	
Phone	<PtPhoneH>	Mobile	<PtPhoneMob>	
Date of Birth	<PtDoB>	Sex	<PtSex>	
Address : <PtAddress>	
Referral information 	
o Patient has GPMP (item 721 or review item 732) AND TCA (item 723 or review item 732)	
o Patient has Mental Health Care Plan	
o Patient has DVA D904 Referral	
o Other: 	
Note: Please include attach copy of relevant part of patient’s care plan to this form
Referral can be made out to specific  CFIH practitioner or to the Centre for Integrative Health	

I would like your assistance in developing an appropriate treatment plan specific to their current medical, physical or other needs. 

I would like to draw your attention to this patient’s current medical / health condition and concerns:
Medical History List  <PMHActive>

Signature
Referrer name: <DrDetails>
Date: <TodaysDate>