Referral form for the Refugee Health Nurse Program 
Please complete as much of the information as known then email or fax to NSW RHS
Email to:  RHS.Referrals@sswahs.nsw.gov.au	Fax to: 	(02) 8778 0790	

Client details	
Surname
	<<Patient Demographics:Surname>>	
First name
	<<Patient Demographics:First Name>>	
Other names
		
Date of birth
	<<Patient Demographics:DOB>>	
Country of birth
	<<Patient Demographics:Country of Birth>>	
Gender
	<<Patient Demographics:Gender>>	
HEMS number (if known)
		
Medicare Number (include position number on card)	<<Patient Demographics:Medicare Number>>	
Health care Card Number	<<Patient Demographics:Pension Number>>	

Number of adults in the family

Names of adults
other than client	

	

Number of children in the family	
	
Names of children other than client	

	

	Note:  
Add each person’s details to page 3 of 
this form if you would like to refer them for an assessment	
Language details	
Preferred language 
	<<Patient Demographics:Language Preferred>>	
Other languages spoken
	<<Patient Demographics:Language Spoken>>	
English language proficiency
		
Literacy in own language
		
Interpreter required
	YES / NO	
Interpreter needs (e.g. ethno specific; gender specific)		
Arrival details	
Date of arrival in Australia
		
Visa type
		
Countries of transit
		
Refugee camp abroad 
	YES / NO	Duration in camp (if known)		
Detention in Australia
	YES / NO	Detention duration (if known)

Continued over page

Client Contact details
	
Address
	<<Patient Demographics:Address>>	
Suburb
	<<Patient Demographics:City>>, <<Patient Demographics:Postcode>>	Postcode
					
Contact number (1)
	<<Patient Demographics:Phone (Home)>>	
Contact number (2)
	<<Patient Demographics:Phone (Mobile)>>	
Email (if known)
	<<Patient Demographics:E-mail>>	
Next of kin details
(name; relationship, contact numbers)	<<Patient Demographics:E-mail>>	
Caseworker details
(name; organisation, contact numbers)
		
GP details (if known)
	
GP name
	<<Doctor:Name>>	
GP telephone numbers
	<<Doctor:Phone>>	
GP address, suburb; postcode	<<Doctor:Full Address>>	
GP language 
other than English		
Health information
	
Current health issues/ 
or concerns

	
Health alerts
	YES / NO	If yes, RED / GENERAL
	
Health Undertakings	YES / NO 	If yes, has Health Undertaking Service been contacted?   YES / NO	
Health manifest available 
	YES / NO	
Detention Health discharge summary available	YES / NO	
Referrer details
	
Name
	<<Doctor:Name>>	
Email
		
Organisation (if applicable)
	<<Practice:Name>>	
Relationship to client 
(e.g. caseworker, sponsor) 		
Contact numbers
	<<Practice:Phone>>

Please complete the following details for each family member you would like included in the assessment:

Other family member’s details	
Surname
		
First name
		
Other names
		
Date of birth
		
Gender	MALE  /  FEMALE	
Medicare Number (include position number on card)												
Health care Card Number
												
Current health issues/ 
or concerns

	
Health alerts
	YES / NO	If yes, RED / GENERAL
	
Health Undertakings	YES / NO 	If yes, has Health Undertaking Service been contacted?   YES / NO	
Health manifest available 
	YES / NO	
Detention Health discharge summary available	YES / NO	

Other family member’s details	
Surname
		
First name
		
Other names
		
Date of birth
		
Gender	MALE  /  FEMALE	
Medicare Number (include position number on card)												
Health care Card Number
												
Current health issues/ 
or concerns	

	
Health alerts
	YES / NO	If yes, RED / GENERAL
	
Health Undertakings	YES / NO 	If yes, has Health Undertaking Service been contacted?   YES / NO	
Health manifest available 
	YES / NO	
Detention Health discharge summary available	YES / NO