AJH Intake Form (Medicare/Private Health/Self-funded)
Are you ready to make a referral for a specific participant to AJH for services?
Yes
No
Please complete our
enquiry form
if you are seeking information only and are not ready to provide specific participant details for a referral
Referral being made through
GP Chronic Condition Management Plan
Private Health
Client (Self) Funded
Who is the referral for?
First Name
Last Name
Local Emergency Contact
First Name
Last Name
Phone
Email
Relationship to the person being referred
Service being referred for
Exercise Physiology
Who is the referral for?
First Name
Last Name
Address
Address Line 1
Address Line 2
City
State
Please select...
QLD
NSW
VIC
SA
WA
ACT
NT
TAS
Postcode
Date of Birth
Date
Contact Details
Email
Mobile Phone Number
Home Phone Number
Preferred Method of Contact
Please select...
Email
Mobile Phone
Home Phone
Nominee (See below)
Guardian (See below)
Do you [does the person being referred] speak/use a language other than English as a first language (including non-spoken languages)?
Yes
No
Do you [does the person being referred] require an interpreter for appointments?
Yes
No
Which language?
Are you [does the person being referred] of Aboriginal or Torres Strait Islander origin? (select all that apply)
Please select...
Australian Aboriginal
Torres Strait Islander
Neither Aboriginal nor Torres Strait Islander
Prefer not to say
Do you [[does the person being referred] ] have any of the following? (Please select all that apply)
Formal Guardian
Informal Guardian
Not Applicable
Formal Guardian Contact Details
First Name
Last Name
Phone
Email
Informal Guardian Contact Details
First Name
Last Name
Phone
Email
Referrer Details if different from the person being referred
First Name
Last Name
Phone
Email
Relationship to the person being referred
Local Emergency Contact
First Name
Last Name
Phone
Email
Relationship to the person being referred
Service being referred for
Exercise Physiology
Please note with regards to Therapeutic Intervention - Our practitioners work remotely across SE QLD. Because of this we may not be able to offer face-to-face therapy. If we can't offer face-to-face intervention and telehealt is allowed, is the person being referred willing to have ongoing therapeutic intervention via telehealth (e.g., Teams)?
Yes
No
Please upload a copy of your GP Chronic Condition Management Plan
Which health fund are you with?
Health fund membership number:
Please tell us briefly what your goals are for EP sessions:
Contact Information
