QuIHN Community Withdrawal Program (Detox at Home)
Referral Form

Please return completed form via
Medical Objects to:

QuIHN Community Withdrawal Program 4737485W

Questions: Contact us on 07 5520 7900		

Program Details
The Community Withdrawal Program (Detox at Home) is for patients with a substance dependence, predicted to experience low to moderate signs and symptoms of withdrawal wish to undergo withdrawal (detox) from the comfort of their own home. Patients will be supported by a team that includes an Alcohol and Other Drugs (AOD) Nurse Practitioner, Registered Nurse, Counsellors, as well as a support person and possibly the patient's GP, if required.

All details below must be completed in full or the referral will be returned. The referrer will be contacted when referral is received and notified of assessment outcome once completed. Patient will be contacted to complete the intake process to further assess for eligibility.

Eligibility Criteria - detailed information can be found here: QuIHN - Community Withdrawal Program - Gold Coast Primary Health Network (gcphn.org.au) 
•	18 years of age and over: <<Eligibility: Is the patient 18 years of age and over?>>
•	Stable housing: <<Eligibility: Is the patient in stable housing?>>
•	Pregnant: <<Eligibility: Is the patient pregnant?>>
•	History of alcohol related seizures: <<Eligibility: History of alcohol related seizures?>>
•	Stable mental and general health: <<Eligibility: Stable mental and general health?>>

Eligibility Criteria met: <<Does your patient meet all eligibility criteria?>>

Patient Consent obtained: <<Has the patient provided consent for this referral>>

Referring General Practitioner/Health Professional
Name: <<Miscellaneous:Current User>>	Profession: <<Referrer's Profession>>	
Practice Name: <<Practice:Name>>	Practice Phone: <<Practice:Phone>>	
Address: <<Practice:Address>>	Email: <<Practice:E-mail>>	

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

Patient Details
RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Gender: <<Patient Demographics:Gender>>	Home Phone: <<Patient Demographics:Phone (Home)>>  Mobile Phone: <<Patient Demographics:Phone (Mobile)>>	
Address: <<Patient Demographics:Full Address>>	Email: <<Patient Demographics:E-mail>>	

Primary substance of concern: <<Primary substance of concern>>
	If other, please specify: <<Primary substance - if other, please specify>>

Secondary substance of concern: <<Secondary substance of concern>>
	If other, please specify: <<Secondary substance - if other, please specify>>

Pathology results if less than 4 weeks old:
<<Pathology results if less than 4 weeks old>>

Minimum Blood Tests if available:
FBC, LFTs, Coagulation, BBVs (if risks identified)

Pulse <<Pulse>>
Weight <<Weight>>
Blood pressure <<Blood pressure>>

Medical History:
<<Clinical Details:History List>>

Current Medications: 
<<Clinical Details:Medication List>>

Privacy Policy: All information provided is protected under the QuIHN Privacy Policy: Privacy — QuIHN