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Referral for The COACH Program

Personal information, including sensitive information, collected by Queensland Health is handled in accordance with the Information Privacy Act 2009. The purpose of this form is so that patients may be referred to The COACH program for care and treatment. All personal information will be securely stored and only accessible by authorised officers of the department. Personal information will not be disclosed to third parties without consent, unless required or authorised by law.

For information about the right to access personal information visit 'Health records and personal information' on the Queensland Health website.

Required fields are marked with an asterisk (*).
Client's details
Sex: *
Date of birth: *
(if known)
Date of discharge
Aboriginal and Torres Strait Islander origin?
Aboriginal and Torres Strait Islander origin?
Contact information
(best phone number for contact)
Preferred contact time:
(tick all that apply)
Preferred day of the week:
(tick all that apply)
Can we leave a message?
Translating and Interpreting Service required?
Health information
Primary health concern: *
(select all applicable)
Referrer's details
(hospital, clinic, self-referral)
Please update me on my patient's progress
Health practitioner's declaration *

  • given the patient a verbal explanation of The COACH Program or provided the patient with a copy of The COACH Program brochure which details their privacy rights.
  • informed the patient that their personal information, including health information, will be provided to Queensland Health, for referral to The COACH Program.
  • informed the patient that Queensland Health will contact them direct in relation to their referral and participation in The COACH Program.

Related information

Last updated: 4 April 2019