Footprints Community – Social Health Connect (SHC) Referral Form

This social prescribing program connects patients to a range of non-clinical services to improve their health 
and well-being. It builds on the evidence that addressing social determinants of health is key to improving health outcomes.
Secure electronic transfer to: SF4006000X1

SHC eligibility criteria (will have to meet all the below, please tick):	
Aged 18 years or older	<<Aged 18 years or older>>	
Does the client have unmet social needs negatively impacting on their health and wellbeing: 
	<<Client has unmet social needs impacting their health>>	
Residing in the Caboolture, Redcliffe or Kilcoy region	<<Residing in Caboolture/Kilcoy or Redcliffe region>>	
Consent	
Is the client aware of this referral?             <<Is the client aware of this referral>>             
Does the client consent to the referral?     <<Does the client consent to the referral>> 	
Referral details	
Date:	<<Miscellaneous:Date (short)>>	
Name:	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	
DOB:	<<Patient Demographics:DOB>>	
Gender:	<<Patient Demographics:Gender>>	
Pronouns (If applicable)	<<Patient Demographics:he/she>>	
Country of Birth	<<Patient Demographics:Country of Birth>> 	
Residency	<<Residency>>  	
Culturally and Linguistically Diverse?	<<Culturally and Linguistically Diverse?>>	
Cultural Background	<<Patient Demographics:Ethnicity>>	
Interpreter Needed	<<Patient Demographics:Requires Interpreter>> 	
Languages spoken at home	<<Patient Demographics:Language Spoken>>	
Aboriginal or Torres Strait Islander	<<Patient Demographics:ATSI>>	
Contact Details	
Phone (Mobile):
Phone (home):
Email:	<<Patient Demographics:Phone (Mobile)>>
<<Patient Demographics:Phone (Home)>>
<<Patient Demographics:E-mail>>	
Preferred Method of contact	 <<Preferred method of contact>>	
Comments regarding contact:	<<Comments regarding contact>>	
Client street Adress	<<Patient Demographics:Full Address>>	
Safety issues
Comments:	<<Safety issues>>
<<If safety issues, please comment>>	
Emergency Contact:	Name: <<Patient Demographics:Emergency Contact>> Relationship: <<Patient Demographics:Emergency Contact Relationship>>	
Emergency Contact phone/email	<<Patient Demographics:Emergency Contact Phone>> 
<<Emergency Contact Email>>	
Reasons for Referral:	
<<Reason for referral>>
	
Other health practitioners/ key persons involved in care:	
<<Health practitioner/key persons involved in care>>
NDIS <<NDIS>>
My Aged Care <<My Aged Care>>
	
Psychosocial Risk Factors/Barriers to social engagement (social, physical, environmental):	
<<Social, physical, environmental risk factors/barriers >>
	
Referrer Details:	
Practitioner Details:	 <<Practice/Location:Name>>
 Referrer relationship to client: <<Referrer relationship to client>>
 <<Doctor:Name>>
 <<Doctor:Provider Number>>
 <<Practice/Location:Address>>
 <<Practice/Location:E-mail>>		
Phone:	<<Practice/Location:Phone>> 	Date of Referral:	<<Miscellaneous:Date>>		Fax number		
To send a referral or contact our team:				
Email: shc@footprintscommunity.org.au 
Phone: 07 32523488
Fax: 07 3252 3688
Medical Objects: SF4006000X1				

Footprints Community - Social Health Connect - v3.0 MD 08/09/2025