Client Support Referral - Newcastle and Hunter Community Health

If you know someone who may benefit from our personalised health services and care, take a moment to fill in our referral form.

All information provided will be kept confidential and will be used at a later date to make contact and discuss a better care plan for the referred individual.

If you choose Newcastle and Hunter Community Health as your service provider we will work with you and your family/decision maker to ensure all your health needs and financial plans are being acknowledged.

Client contact details

First name*

Last name*

Email*

Date of birth*

Day/Month/Year

Home phone number

Mobile phone number

Address*

Gender*

Client profile (about me)*

e.g. Client is XXX years old, client requires XXX care

Guardian contact details (if applicable)

Type of guardian/ advocate:

First name

Last name

Email address

Home phone number

Mobile phone number

Work phone number

Address

Emergency contact details (if different to guardian)

Please confirm if the emergency contact details differ from the guardian contact details*

Yes

First name

Last name

Email address

Home phone number

Mobile phone number

Work phone number

Address

Referrer contact details

First name*

Last name*

Email address*

Mobile phone number*

Position*

Organisation*

Reason for referral*

Further client details

Country of Birth*

Preferred language*

Aboriginal or Torres Strait Islander?*

Yes

Interpreter Required?*

Yes

Does the client have any physical health conditions?*

Yes

If the client has existing physical health conditions please list below and provide GP contact information:

Does the client have any mental health conditions?*

Yes

If the client has existing mental health conditions please list below and provide treating specialist information:

Can the client sign their own agreement and care plan?*

Yes

If not what why and what support is required?

Does the client have any positive behaviour support? *

Yes

If yes, please provide more information:

Please provide any further information regarding client alerts/risks/precautions

Please provide details of client support services required and any further information*

E.g. Personal Care / Domestic Assistance / Daily Supports / Social Support / Respite / Clinical Care by a Registered Nurse

Number of staff required per service

Preferred visit times (morning):*

Preferred visit times (afternoon):*

Please advise who to contact for confirming client appointments*

Type of accommodation and access: *

How does the client communicate:*

Covid vaccination status:*

Are there other services involved?*

Yes

Please provide further information on other services involved:

Has client been discharged or changed providers?*

Yes

Please provide further information if the client has been discharged or changed providers:

Funding details

NDIS Referral: please complete fields below or attach plan

Please attach NDIS referral plan (if applicable)

If you have more than one file, please select them all at once or provide a zip. folder

NDIS number*

NDIS plan start date*

Day/Month/Year

NDIS plan end date*

Day/Month/Year

NDIS plan goals*

NDIS Funds managed by*

NDIS plan manager name*

NDIS plan manager contact number*

Funds to be allocated from:*

Core

Capacity Building

OR

Home care package referral

Package level

Current provider details or first package

HCP Referral code

HCP allocation expiry date

Day/Month/Year

Additional supporting documents

Please attach relevant information such as behaviour support or allied health plans, medical/hospital referrals for clinical services.

If you have more than one file, please select them all at once or provide a zip. folder

Client/ Guardian Declaration