Telecare Specialist Clinic - Uniting Referral Form

Referrer / Case Manager details

Referrer/ Case manager name: *

Email address: *

Funding *

GP Referral Letter *

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Patient Details

First Name: *

Last Name: *

Date of birth *

Phone Number: *

Address:

Postcode:

Email Address: *

Identify as Aboriginal/Torres Strait Islander?

Yes No Choose not to say

Interpreter Required?

YesNo

Next of Kin / Parent / Guardian name (if applicable)

Phone number *

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Specialist appointment you are requesting to arrange (more than one can be selected) *

PaediatricianPsychologistPsychiatristOther

Other specialty not listed:

Reason for referral: *

Other (please specify reason for referral) *

Past Medical History:

Upload GP Referral (if applicable)

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Supporting documents

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Additional comments:

Phone:

Uniting Branch

Other (please specify your branch) *

Fax:

Client consent obtained for referral. *

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