Referral Form

Murrumbidgee Wellness and Resilience Achieved Through Allied Health (WARATAH) Program

PHONE	1300 402 585	
EMAIL	waratah@marathonhealth.com.au	
ARGUS	waratah@marathonhealth.com.au	

GP NAME	<DrName>	
GP ADDRESS	<DrAddress>	
GP PHONE	<DrPhone>	
Client Details

Date of referral	<TodaysDate>	Client’s name	<PtFullName>	
Date of birth	<PtDoB>	Country of birth	<PtEthnicity>	
Phone	<PtPhoneMob>	Address	<PtAddress>	
Carer’s name	<NOKName>	Carer’s Phone	<NOKContact>	
	
Aboriginal or Torres Strait Islander Heritage	<Aboriginal or Torres Strait Islander Heritage>	
Culturally or Linguistically Diverse background	<Culturally or Linguistically Diverse background>	
Main language spoken at home	<Main language spoken at home>	
Interpreter Required	<Interpreter Required>	
Preferred language including sign language, required communication devices or special interpreter needs	<Preferred language>	
	
Current smoker	<Current smoker>	Ex-smoker	<Ex-smoker>	
Current GP Management Plan	<Current GP Management Plan>	Current Health Care Card	<Current Health Care Card>	
If eligible, has client exhausted their MBS funded allied health services under a GPMP or TCA	<If eligible, has client exhausted their MBS funded allied health services under a GPMP or TCA>	

Medical History
Has the client been diagnosed with any of the following conditions (client requires at least one to be eligible):

Obesity	<Obesity>	At risk of Obesity (youth)	<At risk of Obesity (youth)>	
Diabetes	<Diabetes>	Chronic pain	<Chronic pain>	
Osteoarthritis	<Osteoarthritis>	Frailty	<Frailty>	
Chronic Respiratory Disease	<Chronic Respiratory Disease>	Physical inactivity	<Physical inactivity>	

Other Relevant Medical History

   <Other Relevant Medical History>

   Referral – Service Type and Location

Please note referrals to this program can only be made to locations and Allied Health Disciplines where listed in the WARATAH GP information pack.

Please indicate service and location using options below:

Dietetics <Dietetics>
Diabetes Education <Diabetes Education>
Physiotherapy <Physiotherapy>
Podiatry <Podiatry>
Additional information (eg preferred practice):
<Additional information (eg preferred practice):>

Health Linker

Have you identified additional complexities and/or social circumstances getting in the way of a person being able to prioritise and work towards achieving their health care goals?	
<Have you identified additional complexities and/or social circumstances getting in the way of a person being able to prioritise and work towards achieving their health care goals?>	
If yes would you also like your patient to be connected to a WARATAH Health Linker?
If yes, please let them know you have indicated this as part of the referral and that they can expect a call from the Health Linker within the next 7 days.	
<If yes would you also like your patient to be connected to a WARATAH Health Linker?>

    Additional Information to support Health Linker

      <Additional Information to support Health Linker>

Consent for referral provided by client	<Consent for referral provided by client>	

   Please return referral to waratah@marathonhealth.com.au
   If you would like to discuss the WARATAH program in further detail please ring 1300 402 585.