Barwon Regional Adolescent and Child Health Shared-Care (BRANCHS) Clinic
Phone: (03) 4215 1680    
Fax: (03) 4215 1685

Version 1
August 2022

REFERRED BY
Name: <<Doctor:Name>>
Practice: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Provider #: <<Doctor:Provider Number>>
HPI-I: <<Doctor:HPI-I>>
Email: <<Doctor:E-mail>>

BRANCHS Clinic Referral
Head of service: Dr Lawrence Gray

Referral date: <<Miscellaneous:Date (short)>>
Urgency: <<Referral urgency>>
Feedback requested: <<Feedback requested>>

<<Referral criteria- Shared care management>>

PATIENT DETAILS
First Name: <<Patient Demographics:First Name>>
Surname:<<Patient Demographics:Surname>>
DOB: <<Patient Demographics:DOB>>
Gender:<<Patient Demographics:Gender>>
Address: <<Patient Demographics:Full Address>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>
Primary carer/guardian name: <<Patient Demographics:Next of Kin>>
Primary carer/guardian relationship: <<Patient Demographics:Next of Kin Relationship>>
Primary carer/guardian phone: <<Patient Demographics:Next of Kin Phone>>

ATSI: <<Patient Demographics:ATSI>>
Country of Birth: <<Patient Demographics:Country of Birth>>
Interpreter Required:<<Patient Demographics:Requires Interpreter>>
Language: <<Patient Demographics:Language Preferred>>
IHI: <<Patient Demographics:IHI>>
Medicare #: <<Patient Demographics:Medicare Number>>
Medicare expiry: <<Patient Demographics:Medicare Expiry Date>>
Healthcare/Concession :<<Patient Demographics:Pension Number>>
Health Insurance:<<Patient Demographics:Health Insurance>>

REFERRAL DETAILS & SHARED CAREPLANNING
Are you the patient's usual GP? <<Are you the patient's usual GP?>>
If no, please provide the name and practice location of usual GP?  <<Usual GP name and location if different?>>
Are you prepared to participate in a shared-care arrangement for this patient? <<Are you prepared for shared-care management?>>
If no, please indicate if there is capacity within your practice for another GP to manage primary shared-care for this patient? <<If no, can another GP in your practice manage?>>
Preferred days of the week you are available to be contacted by phone and for case conferencing? <<Days of week available to be contacted?>>
If required, are you agreeable to co-prescribing for stimulants, anxiolytics etc in collaboration with the child health team? <<Are you agreeable to stimulant co-prescribing?>>

PATIENT/GUARDIAN CONSENT
Patient/guardian consents to sharing medical information: <<Patient/guardian consents to sharing information?>>
Patient/guardian consents to this referral and to management under a shared-care arrangement <<Patient/guardian consent to this referral?>>
Patient/guardian consents to BRANCHS team contacting the child's school/kinder? <<Consent to contact the child's school/kinder?>> 
Name of current school/ kinder?  <<Name of current school/kinder>>

REASON FOR REFERRAL 
Has this referral been informed by the relevant clinical HealthPathway? <<Referral informed by relevant HealthPathway?>>

<<Detailed history of presenting complaint for triage>>

What management issues would you like addressed?
<<What issues would you like addressed?>>
What are the family's/patient's key concerns? 
<<What are the family's / patient's key concerns?>>
Is this condition currently affecting the patient’s participation in usual activities (including school attendance)?    
<<Is condition currently affecting usual daily activities?>> 
If yes, please describe?
<<If yes, please describe degree of severity>>
Are there other supports in place? (Allied Health, Early Intervention, Education support, Social supports, DFFH) <<Are there other supports in place (eg AH, DFFH)? >>
If yes, please describe and fax relevant reports with referral <<If yes please describe and fax relevant reports>>

RELEVANT PAST MEDICAL AND SURGICAL HISTORY
<<Clinical Details:History List>>

PSYCHOSOCIAL HISTORY
<<Clinical Details:Social History>>

Is child in Out of Home Care? <<Is child in Out of Home Care?>>
Does child have Refugee status? <<Does child have refugee status?>> 
Family history and other relevant factors? <<Family history and other relevant factors?>>

MEDICATION (please ensure this is accurate)
<<Clinical Details:Medication List>>

ALLERGIES
<<Clinical Details:Allergies/Adverse Reactions>>

OTHER SPECIAL ALERTS
<<Clinical Details:Warnings>>

DIETARY STATUS
<<Dietary status (if applicable)? >>

HAVE ANY INVESTIGATIONS BEEN ORDERED? 
<<List any investigations/tests ordered>>

RELEVANT RESULTS AND INVESTIGATIONS:
<<Summary:Investigation Results (Selected)>>

Please include any relevant reports or cc investigation results ordered to BRANCHS clinic

GP signature: ________________________________________________________________________

<PtName> <DrName><<Patient Demographics:Full Name>> <<Patient Demographics:First Name>>  <<Patient Demographics:Surname>> <<Doctor:Name>>