Referral Form

Think, Eat and Move (TEAM) Program is an eight week, evidence based healthy lifestyle program for 13 to 17 year old who are above a healthy weight. The program is free for young people in the Central and Eastern Sydney area and includes online sessions, videos and activities, and regular phone coaching calls with a qualified health professional.	

Fax: 1300 325 301 or Email: info@betterhealthcompany.org	

Family details	
Parent/carer name* :		Relationship to child :		
Contact number* :		Email address:		
Home address: 	

Patient details	
Name* :	<PtFullName>	Date of birth:	<PtDoB>	
Gender:	<PtSex>	Height:	(See Observations below)	Weight:	(See Observations below)	
<Observations>
Comments / other relevant information	

General Practicioner details	
Doctor's name* : <DrName>	
Name of service/practice*: <Practice>	
Phone number: <UsrPhone>