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Mob Link referral

Call us on 1800 254 354, 7 days a week (7 am to 8 pm)

Who to refer

Aboriginal and Torres Strait Islander people living in South East Queensland.

How to refer

Mob Link accepts IUIH Network, external and self referrals. If you can’t use this page’s web form, you can use our standard PDF referral form.

Do you need to provide a referral for a mobility aid prescription? If so, please use our Mobility Aid Prescription referral form.

PH: 1800 254 354

Fax: 07 3205 8666

Email: [email protected]

Mob Link referral

Client referral form

Consent

Has the client consented to this referral?(Required)

Yes

No

Please note, if you answer “No”, Mob Link will not be able to contact the client.

Has the client consented to Mob Link accessing IUIH medical records (if available)?(Required)

Yes

No

Client identifies as(Required)

Aboriginal

Torres Strait Islander

Aboriginal and Torres Strait Islander

Family of Aboriginal and/or Torres Strait Islander

None of the above

Family of

Please provide details of the family connection.

Thank you

Please note: without consent, Mob Link will not be able to contact the client. Mob Link services are available to Aboriginal and/or Torres Strait Islander people and immediate family.

Client details

Name(Required)

Title First name Last name

Date of birth(Required)

Day

Month

Year

This field is hidden when viewing the form

Age

Gender/Sex(Required)

Male

Female

Other

Gender (Other)

Address type(Required)

Fixed address

No fixed address

Address(Required)

Street Address Suburb Post Code

Preferred contact method(Required)

Phone

Email

Neither available

⚠️ Please note: If the client has no form of contact, Mob Link will only be able to communicate with the referrer.

Phone(Required)

Email(Required)

Medicare number

Medicare Index

Medicare expiry

Does the client have a carer, or are they under 18?(Required)

Yes

No

Carer name(Required)

First Last

Phone(Required)

Relationship to client(Required)

Make primary carer?(Required)

Yes

No

Is there a different emergency contact?(Required)

Yes

No

Emergency contact name(Required)

First Last

Phone(Required)

Relationship to client(Required)

Are there child safety or youth justice orders?(Required)

Yes

No

If yes, please provide Authority to Care

Accepted file types: pdf, jpg, png, docx, Max. file size: 20 MB.

Does Mob Link have consent to contact any relevant services?(Required)

Yes

No

Referral Details

This field is hidden when viewing the form

Referral Date

Day

Month

Year

Urgency of referral(Required)

Urgent (priority response required)

Standard referral (routine)

Is the client currently in hospital?(Required)

Yes

No

Hospital URN(Required)

Facility/Ward(Required)

Expected discharge date(Required)

Day

Month

Year

Provide details if they are under the care of any specialty teams(Required)

Is the client currently in a facility?(Required)

Yes

No

Facility type(Required)

For example: prison, transition, or domestic violence

Facility Address(Required)

Street Address City ZIP / Postal Code

Reason for referral—please provide a detailed explanation of reason for referral(Required)

Supporting documents

Max. file size: 50 MB.

Please attach any supporting documents (ie Discharge summary, OT report)

Referrer details

To be contacted regarding referral

Name(Required)

First Last

Phone(Required)

Email(Required)

Organisation/s(Required)

Position(Required)

Department(Required)

PDF copy of this referral

Please email me a PDF copy of this referral

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This website contains images, names, and voices of Aboriginal and Torres Strait Islander people who have passed away. With permission from their families, we have continued to use their images to acknowledge and honour their contributions in making our communities healthy and strong.