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:	<TodaysDate>	
Name:	<PtFullName> 	
DOB:	<PtDoB>	
Gender:	<GenderIdentity>	
Pronouns (If applicable)	<HeSheThey>	
Country of Birth	 <Country of birth>	
Residency	<Residency>  	
Culturally and Linguistically Diverse?	<Culturally and Linguistically Diverse?>	
Cultural Background	<PtEthnicity>	
Interpreter Needed	 <Interpreter required>	
Languages spoken at home	<Languages spoken at home>	
Aboriginal or Torres Strait Islander	<Aboriginal or Torres Strait Islander>	
Contact Details	
Phone (Mobile):
Phone (home):
Email:	<PtPhoneMob>
<PtPhoneH>
<PtEmail>	
Preferred Method of contact	 <Preferred method of contact>	
Comments regarding contact:	<Comments regarding contact>	
Client street Adress	<PtAddress>	
Safety issues
Comments:	<Safety issues>
<If safety issues, please comment>	
Emergency Contact:	Name:  <NOKName>  Relationship: <NOKRelation>	
Emergency Contact phone/email	 <NOKContact>
<Emergency Contact Email (if applicable)>
	
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>
 Referrer relationship to client: <Referrer relationship to client>
 <DrName>
 <DrProviderNo>
 <UsrAddress>
 <PracEmail>		
Phone:	<UsrPhone> 	Date of Referral:	<TodaysDate>		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 BP 08/09/2025