Integrated Team Care (ITC) Program for Aboriginal and Torres Strait Islander people
Referral To:	Referral Date: _________________	
North Western Melbourne PHN             
PO Box 139                                    
Parkville, Vic, 3052       	Phone: (03) 90884272              Secure Fax: 03 9348 0750                           Email: ccss@nwmphn.org.au	
Patient Details: 	
Surname:                                                                First Name:                                                                                                   	
Date of Birth:                                                          Gender:    F      M       Other   Unknown	
Contact Number(s):	Medicare number:	
Residential Address: 	
Alternate contact:                                             Name:                                                              Ph: 	
My patient fulfils all the criteria below 	
          Is Aboriginal, or Torres Strait Islander, or Aboriginal and Torres Strait Islander 	
         Has chronic and complex health needs and requires multidisciplinary care 	
         Has a Care Plan/GP Management Plan. Attach patients care plan with referral 	
         Has given verbal or written consent to be contacted by the Care Coordinator and to participate in the ITC program   	
Reason for Referral 	

	
Referrer Details 	
GP Name:	Practice Name:	
Phone Number:  
GP Provider Number:	Email:	
Practice Address:	
Allocated Care Coordinator:                                                                   Allocated Outreach Worker: 	
Patient Information and Consent 	
•	My GP has explained the purpose of this referral for the ITC Aboriginal Health Program
•	I give permission for my medical information to be shared with the care coordinator
•	I understand that all information is held in strict confidence in accordance with our privacy policies	
Patient name and signature:                                                               Date: