Step 1 of 812%Client DetailsName(Required) First Last Date of birth(Required) Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City Region Postcode Claim or reference number (if applicable)Is this referral for an injury?(Required) Yes NoDate of Injury Injury Diagnosis/DescriptionReferrer DetailsADMIN NOTE(Required – Referrer is the debtor under PIC)Referring Organisation(Required)Referrer Name(Required) First Last Referrer Phone(Required)Referrer Email(Required) Invoice Email(Required) PO number(Required)Is the report to go to the Referrer Yes No – please provide details of recipient of reportRecipient of report, Name(Required) First Last Recipient of report, Phone(Required)Recipient of report, Email(Required) Employment & Work ContextCurrent employment status: Employed – working full duties Employed – fully unfit or reduced capacity Self‑employed – working full duties Self‑employed – fully unfit or reduced capacity Not currently in employment Other – please specifyOther employment statusIs return to work or work participation a goal? Yes No UnsureEmployer name (if applicable)Job titleWork LocationBrief description of role / key duties (if applicable)Reason for ReferralHealth condition / injury type (tick all that apply): Musculoskeletal injury Gradual process injury Concussion / mild TBI Mental health condition Post‑surgical recovery Chronic pain Cancer or medical illness Neurological condition Other (please specify)Other reason for referralPrimary reason for referralDesired outcomeBrief background / relevant history (optional)Treatment Providers Complete relevant providersGeneral Practitioner (GP)NameClinic NameEmail PhoneSpecialistNameClinic NameEmail PhoneTreating ProviderNameClinic NameEmail PhoneOtherNameClinic NameEmail PhoneRequested Service TypeWhat service are you referring for (tick all that applies)? Initial Assessment (Includes assessment, liaison, reporting, and recommendations) Ongoing Lead Provider support (post‑assessment – subject to approval) Treatment / therapy / rehabilitation (subject to approval)This referral approves the initial assessment only. Any additional recommended services will be outlined after assessment and require referrer’s further approval.Consent & Information SharingHas the client consented to this referral?(Required) YesCan TBI Health contact the employer (if applicable)? Yes No Not applicableAttachmentsUpload any relevant documents: Drop files here or Select filesMax. file size: 256 MB.Declaration & SubmissionDeclaration(Required) I confirm that the information provided is accurate and that I am authorised to make this referral. I understand that this referral approves the initial Private Integrated Care assessment only, and any additional services will require further approval.Name First Last Date
