Refer a patient | The Midlife Foundation

1. About you, the referrer

So we can confirm the referral and keep you informed.

Your full name

Your profession

Practice or organisation

Practice postcode

Your email

Your phone

Registration number (optional)If you are registered with the Australian Health Practitioner Regulation Agency.

2. About the woman you are referring

We only need contact details and eligibility. Please do not include diagnoses, test results or medicines.

First name

Last name (optional)She can use a first name only if she prefers.

How would she like us to contact her?

Phone call Text message Email Through me, the referrer

Her mobile phone

Her email

Her postcode

Her age

Does she need an interpreter?

No Yes

Which language?

Does she identify as Aboriginal or Torres Strait Islander? Only with her agreement. Places are set aside for Aboriginal and Torres Strait Islander women.

No Yes She prefers not to say I have not asked

Any access or cultural needs? (optional)For example: a female facilitator only, a support person, hearing or vision needs, no camera.

3. Programme and eligibility

Funded places are for women who could not otherwise afford support.

Which programme are you referring her to?

A funded place in the eight week education programme Free community health education workshops Know before sessions (late thirties and early forties) Not sure, please advise

Which of these apply to her? (choose any that apply)

Holds a concession card Lives with disability Lives in a regional or remote area Aboriginal or Torres Strait Islander From a migrant or refugee community Cannot otherwise afford support

Briefly, what would she like help with? (optional)General topics only, for example: understanding perimenopause, bladder and pelvic health, sexual health, talking to her doctor.

4. Consent and declarations

A referral can only be made with her agreement.

She has agreed to this referral and to The Midlife Foundation contacting her.

How did she give consent?

Verbally, recorded in her notes In writing

She understands the programme is education only and does not replace her medical care. I will continue to provide or arrange her clinical care. This form is not for urgent care. I will arrange urgent care through usual services. I agree to The Midlife Foundation storing and using these details to assess and respond to this form, as set out in the privacy policy. I understand the form host may store data outside Australia.

(choose any that apply)

With her agreement, tell me when she takes up a place

Your full name as signature Typing your name here is your signature.

Date