Refer Someone To QPP

Refer Someone to QPP for Support

For your privacy, all referrals completed via this online form are secure.

If you prefer to complete your referral offline, please download the referral form here to complete and email or fax us on 07 3891 1830 at your convenience.

Referral Form

"*" indicates required fields

Details of the REFERRER

Name*

Organisation*

Position*

Contact Phone*

Email*

Has the client consented to this referral?*

Yes

QPP is unable to provide services to a person where consent for the referral has not been obtained. Please contact QPP to discuss further on 07 3013 5555 or encourage the person to self -refer themselves at https://www.qpp.org.au/self-referral.

New Client Details

Surname*

First Name*

Mobile Phone

Home Phone

Home Address

Can a message be left / contact made*

By Email

On clients home phone

On clients mobile phone

By text to clients mobile phone

Are there confidentiality concerns?*

Yes

Details

Date of Birth*

Day

Month

Year

Country of Birth*

Medicare Eligibility*

Eligible

Ineligible

Interpreter required*

Yes

Language

Gender*

Male

Female

Transgender

Non-binary/gender diverse

Other

Client identifies as*

Aboriginal

Torres Strait Islander

Aboriginal & Torres Strait Islander

Neither

Does the client have a personal carer

Yes

Details

Any issues for support identified by the referrer (or other relevant information)

Support choices

Peer Navigation (for newly diagnosed / HIV health literacy)

Peer Group social activities

Aged Care Navigation (for older people in the Brisbane region only)

Transport

Alcohol & other drugs

Treatment support (access & adherence)

Finances

Mental Health

Housing

Stigma / Discrimination

Legal / Immigration / Visa

Employment

Dental / Oral Health

Other relevant information

Issues identified by the client being referred

Risk Assessment

Are there any known risks associated with this referral*

Yes

Please Specify

Previous physical assault

Previous verbal aggression

History of dangerous weapons use

History of sexual harassment

If yes, Please specify

Confirmation of HIV status

HIV status can only be confirmed by a client’s GP, HIV Specialist, Sexual health Nurse or POCT

Is the person being referred HIV positive?

Yes

Unknown

I confirm that the above named client is HIV positive*

Date (Todays Date)

DD slash MM slash YYYY

Signature*

Date of HIV diagnosis

Day

Month

Year

Date of last test

Day

Month

Year

Viral load at last test (optional)

CD4 Count at last test (optional)

For POCT only

Has diagnosis been confirmed?

Yes

Pending

Phone

This field is for validation purposes and should be left unchanged.