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Allied-health referral letter template

Australian documentation guide

Help the receiving professional understand the person's goals and the question you want them to address. Use this referral body to bring together the relevant history, assessment and precautions.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

A helpful referral explains the person’s priorities and the question you want the receiving professional to address. This template is the clinical letter body. Add the actual patient identifiers, referring-practitioner details, date and signature in your sending system.

State the profession or service requested. The MBS referral requirements allow the person to choose an eligible provider of that type; a named provider is optional. Check the applicable programme separately, including eligibility and required referral particulars.

Reason for referral

Name the profession and the question or service requested, using the clinician’s words and the person’s priorities. “Physiotherapy assessment of difficulty on stairs” is clearer than a broad “please assess and treat”.

Include a provider if one has been chosen. Keep the intervention and urgency to what the clinician stated. A referral being discussed, issued or accepted represents a different stage each time.

Relevant diagnosis or problem

Use the clinician’s stated diagnosis, problem and level of certainty. Keep “established”, “provisional” or “not yet diagnosed” where that is what was said.

A functional concern can be described in its own right. A medicine list, age or requested profession does not supply a disease, stage or severity.

Relevant history

Include the history and findings needed to understand the request, with timing and sources. Identify accompanying reports and whether they were reviewed.

Keep the person’s account and information from others distinct. A reported response to treatment is different from an observed change. Share relevant information within the agreed consent and local process.

Current function and goals

Describe the activities, difficulties and priorities discussed. Include the person’s own goal and any measurement or assessment performed. “Uses a handrail on stairs” gives the next reader something concrete.

Keep exercise tolerance, dietary targets and capacity to the actual assessment. A requested assessment has not already happened, and a suggested goal still needs the person’s agreement.

Current medications

Include the current medicine list or clearly identify the attached list. Keep directions, current use and any incomplete verification visible where relevant.

An old list is not automatically current. Missing doses need clarification, not an assumption. Check that a referenced attachment is included before sending.

Allergies and relevant precautions

Include known allergies, reactions and precautions, with their source and any uncertainty. Keep a clinician-stated restriction’s scope, date and authority clear.

“Not documented” does not mean “no precautions”. Weight-bearing status, exercise clearance and dietary restrictions must come from the clinician’s assessment. Keep this required field’s gaps visible.

Program context

Name the actual pathway: GPCCMP, Better Access, another programme or private referral. Include the plan’s status and sharing consent where established. The headings themselves do not choose a pathway.

Check current programme rules rather than reusing an old form’s defaults. The Better Access guide covers that separate mental health request.

Number of sessions requested

Use the number the clinician requested, where applicable. The MBS note says chronic-condition referrals do not need a service count; Better Access referrals do.

For a chronic-condition referral, “no count specified” can be accurate. Keep it distinct from a decision still outstanding. The template must not prefill five services, calculate unused entitlements or turn an omitted count into a restriction.

Common omissions

Check the requested profession and question, medicine-list source, precautions, programme and sharing consent. Verify attachments and the separate referral particulars. A named provider is optional; the requested profession or service still needs to be clear.

Review before sending

Read the request, diagnoses, goals and restrictions against the assessment. Check the pathway, attachments, sharing consent and recipient details when chosen. The clinician must explicitly confirm the generated letter. This guide makes no treatment or eligibility decision.

Worked examples

A physiotherapy referral draft focused on stairs and a community group

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR REFERRAL: Fictional GP referral to physiotherapy to assess the person's reported difficulty with stairs and discuss management within their agreed goals. No particular exercise programme is prescribed by this letter.
RELEVANT DIAGNOSIS / PROBLEM: GP records established knee osteoarthritis. The diagnosis is taken from the referring clinician's assessment, not inferred from the functional complaint.
RELEVANT HISTORY: Person reports increasing difficulty using the stairs at home over three months. They say they stopped attending their community group because of the stairs at the venue. Earlier assessment information is attached with the person's agreement; a full examination is not repeated in this extract.
CURRENT FUNCTION & GOALS: Person reports walking on level ground independently and using a handrail on stairs. Their stated goal is to attend the community group again. The referral requests the physiotherapist's assessment rather than asserting current exercise capacity.
CURRENT MEDICATIONS: Current verified medicine list is attached. GP states that no medicine change was made at this visit; the referral does not supply an unstated dose.
ALLERGIES & RELEVANT PRECAUTIONS: Person reports no known medicine allergy. GP has not documented a weight-bearing restriction or other exercise precaution in this extract; this absence is not a certification of unrestricted activity.
PROGRAM CONTEXT: Referral is made under the documented GP Chronic Condition Management Plan, with the person's agreement to share the relevant plan and assessment. Eligibility and current referral requirements still need checking before issue.
NUMBER OF SESSIONS REQUESTED: GP does not specify a service count for this chronic-condition referral. No default allocation or funded balance is inferred.

A dietitian referral draft with the programme still unconfirmed

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR REFERRAL: Fictional request for dietitian assessment of meal planning around shift work, reflecting the person's stated concern.
RELEVANT DIAGNOSIS / PROBLEM: GP states that a chronic condition is relevant, but its name and current assessment are not established in this extract.
RELEVANT HISTORY: Person reports variable meal times and difficulty arranging appointments. Other relevant history is not stated.
CURRENT FUNCTION & GOALS: Person wants practical help fitting their meals into their roster. No dietary prescription or clinical target is given in the source.
CURRENT MEDICATIONS: [not stated]
ALLERGIES & RELEVANT PRECAUTIONS: [not stated]
PROGRAM CONTEXT: Whether a GPCCMP, another programme or a private referral is intended remains to be confirmed. Consent to send the relevant records is not yet documented.
NUMBER OF SESSIONS REQUESTED: [not stated]

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.