BIDGERDII COMMUNITY HEALTH SERVICES
AOD – REFERRAL FORM

Client Details:	
Client Name:		
Date of Birth:		
Gender:		
Physical Address:		
Contact Phone:		
Aboriginal and/or Torres Strait Islander Identification:		
Name of GP/Other Referrer:		
Practice Address:		
GP Contact:			
Medicare Card Number:		Expiry Date:		
Concession Card Type and Number (not essential):		Expiry Date:		
Recent Medical History:	
	
Current Medications:	
	
Reason for referral:	

Allied Health Services – Rockhampton / Mount Morgan / Capricorn Coast	
o Dietitian-Nutritionist	o Speech Pathologist	o Alcohol and Other Drugs Counsellor	
o Occupational Therapist (Child)	o Counsellor		

GP/Referrer Approval:	Signature:	Date:	
	Print Name:		

Completed referrals can be FAXED to (07) 49286430 or EMAILED to khall@bidgerdii.org