PCCS Sports on Prescription
Referral Form

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

RE:  <PtDetails>  	DOB: <PtDoB>  	

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	

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>