National Centre Veterans’ Healthcare (NCVH) 
Referral Form	
Site:  Concord Repatriation General Hospital	Ph: (02) 9767 8669       Fax: (02) 9767 5177 
SLHD-ConcordAppointmentCentreACBU@health.nsw.gov.au	

NCVH Specialist Services	
All patients will receive a comprehensive clinical assessment. Referral to all providers facilitates this process. Referral is valid for 12 months.
 
NCVH comprehensive referral (preferred):
□  Dr Winnie Hong (Chronic Pain), Dr Huw Davie (Drug Health), Dr Gavin Angus-Leppan (Psychiatry),
     Dr Justin Tan (Rehabilitation Medicine), Dr Cameron Korb-Wells (A/Medical Director)
 
Or named referral only: 
□  Dr Winnie Hong (Chronic Pain)                                   □   Dr Justin Tan (Rehabilitation Medicine)
□  Dr Huw Davie (Drug Health)                                         □    Dr Cameron Korb-Wells (A/Medical Director)
□  Dr Gavin Angus-Leppan (Psychiatry) 	
Referrer Details (GP referral required)	
Referrer Name:<DrName>	Date of Referral:<TodaysDate>	
Organisation:<Practice>	Provider Number:<DrProviderNo>	
Address<DrAddress>:	
Phone Number: ( <DrPhone> )	Fax: ( <DrFax> )	
Email:<DrEmail>	
Patient Details	
Surname:<PtSurname>	Given Names:<PtFirstName>	
Sex:  <PtSex>	DOB:<PtDoB>	
Address:<PtAddress>	
Phone: (  <PtPhoneMob>  )	Email:<PtEmail>	
Medicare Number:<PtMCNo>	Expiry date:<PtMCExpiry>	
Contact person:<NOKName>	Relationship to patient:<NOKRelation>	
Contact person mobile:<NOKContact>	Other contact person details: <Other contact person details>	
Australian Defence Force (ADF) History	
 
Patient is only eligible for NCVH services if they are a current ADF serving member or has served in the past.
                                                        Is patient a current service ADF member?  □ Yes  □ No
                                                        Has the patient served in ADF in the past? □ Yes  □ No
 	
DVA entitlements: □ Gold  □ White     □ No entitlement               DVA Number: <PtDVANo>	
Years of service: <Years of service>                    Branch of service:<Branch of service>	
Field of ADF work: <Field of ADF work>                    Number of Deployments: <Number of Deployments>	
ADF discharge: □ Voluntary     □ Non-voluntary   |  □ Medical grounds     |  □ Compulsory retirement age	
ADF discharge summary: □ Yes (please attach if available)    □ No	
Receiving ongoing support or treatment relating to military service (please attach notes if applicable):
□ Yes         □ No	
Referral Details	
Reason for referral / diagnosis:

Medical History (please attach additional details if required):
<PMHAll>	
Mental Health Diagnoses (please tick all applicable boxes):
 
□ PTSD        □ Depression          □ Anxiety          □ Panic attacks
 
□ Substance use – current/past; which substance(s)_____________________________________________ 

Other diagnoses:

_______________________________________________________________________________________
	
Current Medications (or attach):
<CurrentRx>
	
Is there a history of concussion or other head injury?     □ Yes        □ No
Are there ongoing issues following the head injury?       □ Yes         □ No
 
Details:	
Has the patient experienced any issues with anger management? □ Yes    □ No
 
Details:
 	
Prior Medical Specialist Contacts (please attach Care Plan if available):
 
1. Chronic Pain: _________________    4.  Rehabilitation Medicine:  _______________________
 
2. Drug Health:  _________________    5. Other:  _______________________________________
 
3. Mental Health:  ____________________	
Other Comments: _______________________________________________________________________________________

 **  Please attach any relevant investigation results and/or ADF Post-Discharge GP Health 
Assessment if available *

Referrer’s signature: _________________________________

Office use only:                                                                                       Practice stamp (if applicable) 	
Date Received:                  1st contact:                       Intake: