REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
REHABILITATION SERVICES CLINIC
COMMUNITY AND INPATIENT REHABILITATION 
Specialising in multidisciplinary care for patients with rehabilitation needs.

SEND TO: Rehabilitation Services
Email: GCHsubacute@health.qld.gov.au
Fax: 07 5635 6411      OR     Phone: 07 5635 6301

Secure transmission service via Medical Objects,
Healthlink to
QHEALTH,GOLD COAST HEALTH Community Rehabilitation Service	FROM <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

<<Miscellaneous:Date (long)>>

Dear Dr Chen

SECTION 1 Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
AGE: <<Patient Demographics:Age>>

Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Full Address>>
Home Ph: <<Patient Demographics:Phone (Home)>>
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Medicare Number*: <<Patient Demographics:Medicare Number>> (*Medicare ineligible patients will incur a consultation fee)
	Next of Kin/Alternative Contact: <<Patient Demographics:Next of Kin>>
Next of Kin/Alternative Contact Ph: <<Patient Demographics:Next of Kin Phone>>
Does patient identify as Aboriginal and/or Torres Strait 
Islander: <<Patient Demographics:ATSI>>
Interpreter required: <<Interpreter required>>
If yes, specify language: <<If yes, specify language>>	

SECTION 2 Reason for referral and additional clinical information	

What is the reason for this referral: <<Specify main reason for referral>>

Please provide provisional diagnosis (if available): <<Provisional diagnosis if available>>

Please include any symptoms and date of onset (if known): <<Symptoms and date of onset if known>>

Paste or type relevant history, rehabilitation goals, examination and treatment to date if required

SECTION 3 Mandatory clinical information

Is a Mental Health Care Plan in place: <<Is a Mental Health Care Plan in place>>

Has a Team Care Arrangement been completed: <<Has a Team Care Arrangement been completed>>
If yes, please attach GPMP/TCA and provider details: <<Attach GPMP/TCA and Provider Details>>

Has the patient got an EPOA or Guardianship Order in place: <<Has the patient got an EPOA or Guardianship Order>>
If yes, please specify details: <<Specify details of EPOA/Guardianship Order>>

Has the patient got access to NDIS or My Aged Care: <<Has patient got access to NDIS or My Aged Care>>
If yes, please specify details: <<If yes, specify details of NDIS/My Aged Care>>

SECTION 4 Investigations
Please attach any investigation results you consider to be relevant, such as recent CT or MRI imaging.

<<Summary:Investigation Results (Selected)>>

SECTION 5 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty;
other factors. Please paste or type relevant information.

SECTION 6 Medical history including co-morbidities and previous surgical interventions

Alcohol: <<Clinical Details:Alcohol>>
Smoking: <<Clinical Details:Smoking>>

<<Clinical Details:History List>>

<<Operation:CoMorbidities>>

<<Operation:Previous Procedures>>

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

Current prescribed medications: <<Clinical Details:Medication List>>

SECTION 7 Information about this specialist service for patients and referring clinicians

This service provides a time limited, goal focused and multidisciplinary rehabilitation service for adults over the age of 18 years. The service delivers a holistic model of restorative and adaptive therapy which focuses on optimising functional capacity and quality of life for clients with identified rehabilitation goals following health events such as stroke, acquired brain injury, multi-trauma and illness.

Disciplines include clinical psychology, dietetics, neuropsychology, nursing, occupational therapy, pharmacy, physiotherapy, rehabilitation consultant, social work and speech pathology.

For further information, please contact the team on one of the below numbers:
Inpatient (GCH or Robina) Rehabilitation Service: 07 5687 3330
Community Rehabilitation Program Service: 07 5635 6301

Referrals will not be accepted if:
•	Client is receiving/referred for:
•	Palliative care services
•	Active oncology treatment
•	Primary clinical need associated with community service and/or equipment set up or residential placement
•	Residing in Residential Aged Care Facilities
•	Returned to previous level of function
•	Clients whose clinical needs are better met by an alternative service (e.g. Aged Care, Chronic Pain, Mental Health, AODS) 	
SMOs/VMOs in this Specialist Service	

Dr Benjamin Chen	Dr Pallavi Bansal	Dr Teresa Boyle	
Dr Hilary Taylor-Evans	Dr Keanming Wong	Dr Natalie Yovenko-Lahovec