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

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

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 6 km 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: <<Miscellaneous:Date (short)>> 

REFERRER DETAILS
Referrer's role	<<Referrer's Role>>	
Referrer's name	<<Doctor:Name>>	
Referrer's email	<<Doctor:E-mail>>	
Practice name	<<Practice:Name>>	
Practice address	<<Practice:Address>>	
Practice phone no	 <<Practice:Phone>>	
Practice fax no	<<Practice:Fax>>	
Provider no	<<Doctor:Provider Number>>	
HealthLink EDI	<<HealthLink EDI>>	

PATIENT DETAILS
Gender  <<Patient Demographics:Sex>> 	Other gender identify (if applicable) <<Patient - other gender Identity (if applicable)>>	
Address  <<Patient Demographics:Full Address>>		
Home phone number  <<Patient Demographics:Phone (Home)>> 	Mobile phone number  <<Patient Demographics:Phone (Mobile)>>	
Aboriginal &/or Torres Strait Islander status  <<Identifies as Aboriginal and/or Torres Strait Islander>>	Culturally or Linguistically Diverse (CALD)  <<Culturally or Linguistically Diverse (CALD)>>
Language spoken at home <<Language spoken at home>>
Is an interpreter required  <<Is an interpreter required>>	
Specify any specific client needs <<Specify any specific client needs>>		
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 <<Social barriers or at risk of poor health outcomes>>	Please provide details of long-term health conditions <<Details of long term health conditions (if applicable)>>	
Does the person have caring responsibilities? <<Does the person have caring responsibilities?>>	Recent hospitalisation <<Recent hospitalisation>>	
Employment status <<Employment status>>	Consent to being referred to Sports on Prescription program and being contacted by the program providers  <<Consent referral to Sports on Prescription/contact>>	
Clinical recommendation <<Clinical recommendation>>	Current physical activity level <<Current physical activity level>>	

Activity type/preference prescription
Bowls (free voucher) <<Bowls (free voucher)>>	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 voucher)>>	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>>	
Please attach any medical history or current treatment plans <<Attach any medical history and/or treatment plans>>