Doctors Referral Lifeworks Occupational Therapy Group Please complete all sections and return by post, fax or email. Please contact Jacintha Bell (OT) on 0403 803 434 if you have any queries. Name of Group: Client Name: D.O.B: Medicare Number: Contact Details: Is the client referred under any of the following programs? (please attach relevant documentation) □ Better Access for Mental Health □ DVA □ Workcover Relevant Psychiatric and/or Medical Conditions: Current Medications: Does the client have a history, or current presentation of any risk factors? Self harm/suicide attempts Violence/aggression Substance abuse Please provide details: □ □ □ Is there any reason why it may be unsafe for this client to attend a community-based group? Referrers details: Name: Designation: Provider Number: Contact details: Signed: Date: