Referral Form

Who can refer?

Anybody caring for a person with a life limiting illness.

When to refer?

Referral may be appropriate at any stage of an illness that is:

advanced
progressive
incurable
potentially life-limiting

SPICT™ (coming soon)

The SPICT™ is used to help identify people whose health is deteriorating.

How to refer?

To the Consult team with Grampians Regional Palliative Care Team referral form faxed to Central Intake on 5320 3893 +/- phone call to GRPCT triage phone 0408 612 699.

Grampians Regional Palliative Care Team referral form.
GRPCT also accept faxed/written referral from GPs and health practitioners.
It is important to be thorough and provide comprehensive information in the referral.

Referral Form (Printable PDF)

Referral Form (Onscreen Fillable PDF)

Contact Us:

GRAMPIANS REGIONAL PALLIATIVE CARE TEAM
Ballarat Health Services, 102 Ascot St Sth, Ballarat 3350
Phone: (03) 5320 6453
Fax: (03) 5320 6493
Clinical triage Ph: 0408 612 699 (8:00am – 4:00pm Mon – Fri)
Em: GRPCTAdmin@gh.org.au