Client Details:
Name:	Alias:
DOB:	Gender: Male Female Not stated Other ______________________
Address:
Home Phone:	Mobile:
Do you identify as: Aboriginal Torres Strait Islander Both
Country of Birth: Australia
Do you speak a language other than English? No Yes (please state)
Medicare Card No: Medicare Expiry Date:	Health Care Card No: Health Care Card Expiry Date:
SA Ambulance Cover: Yes No Membership number:	Advance Care Directive: Power of Attorney:
Medical Clinic:	GP:
Has this client been registered for CTG co-payment and Practice Incentives Program: Yes No Clinic Registered at:
Chronic Disease Details: Diabetes Cardiovascular Disease Cancer Chronic Respiratory Disease Chronic Renal Disease Mental Health Condition Other _____________________________
Does this client have a GP Management plan or Mental Health Treatment Plan: Yes No Review Date:
Does the client have an ATSI Health Check (715): Yes No Date completed:
Emergency / NOK Contact Name:	Phone:
I am happy to be referred to Closing the Gap Riverland (CTGR): Client’s Signature: Date:
Referrer Details (GP or specialist only):
Referrer’s Name:	Referrer’s Organisation:
Referrer’s Address:	Referrer’s Phone Number:
Referrer’s Signature:	Date:

FOR OFFICE USE ONLY

Staff member completing referral form:

Risk Assessment Complete Master Register Complete MMeX Complete CTGR Starter Pack Provided