PCCS Sports on Prescription
Referral Form

Forward completed Referral via Medical Objects to: HEAD (RG4220000HJ)
For more information call us 07 3186 4000

What is Sports on Prescription?
Sports on Prescription links people to FIVE free specific sports sessions that are local and community based and connecting them with a social prescribing link worker to improve their health, wellbeing and quality of life.

The program is for people with a long term health/mental health condition AND unmet psychosocial needs who would benefit from a social prescribing program focused on connection and participation.

Participants in Social Prescribing have reported improvements in health and wellbeing, quality of life, socialisation, social contacts, health related behaviours, and day-to-day functioning, and reductions in frequency of health service utilisation, pain and mental ill health.

Eligibility
Who is eligible?
• People with long-term or chronic health conditions (which can include mental health conditions), AND
• People experiencing one or more unmet psychosocial needs that affect their quality of life, functioning, or participation.
• People over the age of 18 who live within a 6km radius in the following areas: Upper Coomera , Carrara and Nerang area and Burleigh Waters
Who is not eligible?
• Individuals with medical conditions who have not yet received approval from their healthcare provider
• Any person experiencing severe or acute mental health concerns
• People who reside outside the above areas

Referral Date  <TodaysDate>

REFERRER DETAILS

Referrer's role	<Referrer's role>	
Referrer's name	<DrName>	
Referrer's email	<DrEmail>	
Practice name	<Practice>	
Practice address	<UsrAddress>	
Practice phone no	<UsrPhone>	
Practice fax no	<UsrFax>	
Provider  no	<DrProviderNo>	
HealthLink EDI	<HealthLink EDI>	

PATIENT DETAILS	

RE:  <PtDetails>  	DOB: <PtDoB>  	
Gender  <PtSex>	Other gender identity (if applicable)  <Patient - Other Gender Identity (if applicable)>	
Address   <PtAddress>		
Home phone no  <PtPhoneH>  	Mobile phone no  <PtPhoneMob>	
Aboriginal &/or Torres Strait Islander Status  <Does the person identify as Aboriginal &/or TSI>	Culturally or Linguistically Diverse (CALD)  <Culturally or Linguistically Diverse (CALD)>
Language spoken at home  <Language spoken at home> 
Interpreter required  <Is an interpreter required>	
Employment status <Employment status>	Does the person have caring responsibilities <Does the person have caring responsibilities>	
Specify any specific client needs <Specify any specific client needs>	Please provide details of long-term health conditions <Details of long term health conditions (if applicable)>	
Does the person have any social barriers, impacted by isolation/loneliness or to at risk of poor health outcomes associated with social determinants of health <Any social barriers impacted by isolation/loneliness, risk of poor health outcomes associated with social determinants of health>	Recent hospitalisation <Recent hospitalisation>	
Clinical recommendation <Clinical recommendation>	Consent to being referred to Sports on Prescription program and being contacted by the program providers <Consent to referral to Sports on Prescription/contact>	
Cleared for participation <Cleared for participation>	Current physical activity level <Current physical activity level>	

Activity type/preference prescription

Bowls (free voucher) <Bowls>	Volunteering role in a sports club rather than participating in a sport <Volunteering in a sports club rather than participate>	
Pickle ball (free voucher) <Pickle ball>	Free or small fee yoga or workout groups <Free or small fee yoga or workout groups>	
Aqua fitness (free voucher) <Aqua fitness (free voucher)>	Free walking groups <Free walking groups>	
Tennis (free voucher) <Tennis (free voucher)>	Other <Other>	

Additional Information

Anything else we need to know? Describe main concerns and any relevant information (including cultural, medical, medication, developmental, social, emotional or trauma history) <Anything else we need to know - any relevant info>

Attach any plans/history <Attach any plans/history>