Referral Form
COVID Social Care Navigator

GP name:  <DrName> 
GP number:  <DrProviderNo>
GP address: <DrAddress>

Phone (Office):	02 6937 2000
Phone (Mobile):	0409 596 376
Email: COVIDSocialCare@marathonhealth.com.au

The COVID Social Care Navigator Service is available for COVID-19 positive patients who are managed by their GP in the community.
Referrals are for vulnerable community members who are experiencing increased difficulty in navigating and accessing appropriate supports.
Does the patient meet this eligibility criteria?    <Meet this eligibility criteria?>    
Date client confirmed positive: <Date client confirmed positive> 

Client Details

Date of
referral	 <TodaysDate>	Client’s
name	 <PtFullName>	
Date of birth	 <PtDoB>	Gender	 <PtSex>	
Phone	 <PtPhoneMob>	Address	 <PtAddress>	
Next of Kin name	 <NOKName>	Next of Kin phone	 <NOKContact>	
	
Aboriginal or Torres Strait Islander Heritage		 <Aboriginal or Torres Strait Islander Heritage>	
Culturally or Linguistically Diverse background		 <Culturally or Linguistically Diverse background>	
Main language spoken at home		 <Main language spoken at home>	
Interpreter Required		 <Interpreter Required?>	
Preferred language including sign language, required communication devices or special interpreter needs	  <Preferred language?>	

Referral Concerns
<Referral Concerns>

Other Relevant Medical History
<PMHActive>

Consent for referral provided by client		 <Consent for referral provided by client>	

Return referral to COVIDSocialCare@marathonhealth.com.au