Barwon Regional Adolescent and Child Health Shared-Care (BRANCHS) Clinic
Phone: (03) 4215 1680    
Fax: (03) 4215 1685 
	Version 1
August 2022	

REFERRED BY
Name:  Treating Doctor.Name
Practice: Practice.Name
Address: Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Provider #: Treating Doctor.Provider Number
HPI-I:
Email:  Treating Doctor.E-mail

BRANCHS clinic referral
Head of service: Dr Lawrence Gray

Referral date: Miscellaneous.Date
Urgency: Urgency
Feedback requested: Feedback requested	PATIENT DETAILS
First Name: Patient Demographics.First Name
Surname: Patient Demographics.Surname
DOB: Patient Demographics.DOB
Gender: Patient Demographics.Gender
Address: Patient Demographics.Address
Mobile: Patient Demographics.Phone (Mobile)
Email:Patient Demographics.E-mail
Primary carer/guardian name: Patient Demographics.NOK Name
Primary carer/guardian relationship: Patient Demographics.NOK Relationship
Primary carer/guardian phone: Patient Demographics.NOK Mobile Phone

ATSI: Patient Demographics.ATSI Status
Interpreter required: Interpreter required
Language: Language?
IHI:Patient Demographics.IHI Number
Medicare #: Patient Demographics.Medicare Number
Medicare expiry: Patient Demographics.Medicare Expiry Date
Healthcare/concession:Patient Demographics.Pension Number
Health Insurance:Patient Demographics.Health Fund Name
	
REFERRAL DETAILS & SHARED CARE PLANNING
Are you the patient's usual GP? Usual GP?
If no, please provide the name and practice location of usual GP?  Alternate GP details
Are you prepared to participate in a shared-care arrangement for this patient? Shared care capacity
If no, please indicate if there is capacity within your practice for another GP to manage primary shared-care for this patient? Alternate GP
Preferred days of the week you are available to be contacted by phone and for case conferencing? GP availability
If required, are you agreeable to co-prescribing for stimulants, anxiolytics etc in collaboration with the child health team? Co-prescribing
	
PATIENT/GUARDIAN CONSENT
Patient/guardian consents to sharing medical information: Pt consents to infor
Patient/guardian consents to this referral and to management under a shared-care arrangement:Referral consent
Patient/guardian consents to BRANCHS team contacting the child's school/kinder? Schoolkinderconsent
Name of current school/kinder? School/kinder name	

REASON FOR REFERRAL
Has this referral been  informed by the relevant clinical HealthPathway?HealthPathway?

Reason for referral

What management issues would you like addressed?
Issues to address

What are the family's/ patient's key concerns?
Family key concerns
Is this condition currently affecting the patient's participation in usual activities (including school attendance)?    
Daily life 
If yes, please describe?
Degree of severity
Are there other supports in place? (Allied Health, Early Intervention, education supports, social supports, DFFH) 
Other supports
If yes, please describe and fax relevant reports with referral 
Support details	
RELEVANT PAST MEDICAL AND SURGICAL HISTORY
 Clinical Details.Past History
	
PSYCHOSOCIAL HISTORY
Clinical Details.Social History
Is child in Out of Home Care? Is child in Out of H
Does child have Refugee status? Refugee status
Family history and other relevant factors? Family history	
	
MEDICATION (please ensure this is accurate)
Clinical Details.Medications - Current Regular (with comments)

ALLERGIES
Clinical Details.Allergies

OTHER SPECIAL ALERTS
Clinical Details.Warnings

DIETARY STATUS
Dietary status	
	
HAVE ANY INVESTIGATIONS BEEN ORDERED?
Tests ordered?	
RELEVANT RESULTS AND INVESTIGATIONS
 Clinical Details.Result List (Selected)
Please include any relevant reports or cc investigation results ordered to BRANCHS clinic

GP signature: ________________________________________________________________________