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:<<Doctor:Name>>	Date of Referral:<<Miscellaneous:Date (short)>>	
Organisation:<<Practice:Name>>	Provider Number:<<Doctor:Provider Number>>	
Address<<Doctor:Full Address>>:	
Phone Number: ( <<Doctor:Phone>> )	Fax: ( <<Doctor:Fax>> )	
Email:<<Doctor:E-mail>>	
Patient Details	
Surname:<<Patient Demographics:Surname>>	Given Names:<<Patient Demographics:First Name>>	
Sex:  <<Patient Demographics:Gender>>	DOB:<<Patient Demographics:DOB>>	
Address:<<Patient Demographics:Full Address>>	
Phone: (  <<Patient Demographics:Phone (Mobile)>>  )	Email:<<Patient Demographics:E-mail>>	
Medicare Number:<<Patient Demographics:Medicare Number>>	Expiry date: <<Patient Demographics:Medicare Expiry Date>>	
Contact person:<<Patient Demographics:Next of Kin>>	Relationship to patient:<<Patient Demographics:Next of Kin Relationship>>	
Contact person mobile:<<Patient Demographics:Next of Kin Phone>>	Other contact person details:<<Patient Demographics:Emergency Contact>>	
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: <<Patient Demographics:DVA Number>>	
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):
<<Clinical Details:History List>>	
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):
<<Clinical Details:Medication List>>	
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: