Mild Traumatic Brain Injury (TBI) (including Concussion)

ADULT

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    • Patients with severe symptoms indicating potential life-threatening complications or immediate neurological risks, such as:
      • ­Rapidly deteriorating consciousness or sudden confusion
      • ­Increasingly restless, agitated, or combative behaviours
      • ­Acute neurological change (e.g., weakness, hypertonicity, sensory changes)
      • ­Seizures or uncontrollable vomiting
      • ­Signs of raised intracranial pressure (e.g., severe headache, vision changes, unequal pupils)
    • Severe neck pain with suspected spinal cord involvement
    • Refer to HealthPathways for assessment and management recommendations
    • New symptoms post-concussion: Identify symptoms within these domains:
      • ­Physical Complaints: Refer early to concussion service or vestibular physiotherapy for symptoms like headaches, whiplash, balance changes, physical fatigue, dizziness, visual changes or sleep disturbances. Refer to musculoskeletal physiotherapy for concerns with neck pain.
      • ­Emotional Concerns: Consider concomitant MHCP if there is evidence of high emotional distress, concurrent stressors, or new mental health concerns following the injury.
      • ­Cognitive Concerns: Note any cognitive difficulties affecting work or daily activities or causing frustration or distress such as photophobia, hyperacusis, difficulty concentrating, memory changes, or cognitive fatigue.
    • Consider referral to brain injury clinic or Rehabilitation Medicine CPC if suspicion of greater than mild traumatic brain injury
Minimum Referral Criteria
Category 1
(appointment within 30 calendar days)
  • Injury within 3 months with multiple poor prognostic factors and/or high symptom burden in two or more domains (see useful information) preventing any engagement in work/leisure/sport
  • Age 16-18 not attending school with impact on formal education/apprenticeships
  • Age 16-18 attending school and paediatric service with focus on return to schooling not available (Please see Paediatric Mild TBI CPC)

    • NB: Risk factors for poor recovery:

    • High emotional distress post-injury
    • High risk of psychological impact (e.g. assault or domestic violence),
    • Comorbid mental health conditions
    • Significant physical symptom burden
    • Work-related stressors or demands
    • Other psychosocial stressors
    • History of previous concussions, poor premorbid health, chronic pain, migraines, or sleep issues
    • Limited social or family support
Category 2
(appointment within 90 calendar days)
  • Injury within 3 months that doesn't meet Category 1 criteria
  • Injury older than 3 months with moderate symptom burden and some impact on ability to undertake work/leisure or sport activities.
Category 3
(appointment within 365 calendar days)
  • Injury older than 12 months with mild symptom burden and still able to complete most work, leisure and sporting activities

Please insert the below information and minimum referral criteria into referral

1. Reason for request Indicate on the referral

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can't order, or the patient can't afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

2. Essential referral information Referral will be returned without this

  • Date, circumstance, and description of injury (e.g., mechanism of injury such as a fall, sports impact, car accident). If available include
    • ­Injury classification markers such post traumatic amnesia (PTA), Glasgow Coma Scale (GCS) score, loss of consciousness (LOC), and any post-traumatic seizures.
  • Past medical and psychiatric history:
    • ­Include prior brain injuries, concussions, neurodevelopmental issues (e.g., ADHD), chronic pain, sleep disturbances, migraines, and psychological history.
    • ­Past medical and psychiatric history. Include relevant history of alcohol or substance use.
  • Current medications: List of patient’s medications with doses
  • Describe current living situation and available informal and formal supports. Specify previous history of domestic violence or assault risk. Include any barriers to clinic attendance.

3. Additional referral information Useful for processing the referral

  • Summary of any diagnostic tests or imaging performed to date
  • List symptoms with consideration of physical, cognitive, and emotional domains, including any formal screening results (e.g.  Rivermead Post Concussion Symptom Questionnaire, Sport Concussion Assessment Tool 6 (SCAT6) or online, Post Concussion Symptom Scale)
  • Describe effects on daily activities and work including current job role and employment status
  • Outline potential rehabilitation goals, such as support with returning to work, study, or daily activities.
  • Note patient’s response to symptoms, including any signs of distress and coping strategies used.
  • Document any other treatments received, education, specialist care, or alternative medicine interventions.

4. Request

  • Patient's demographic details

    • Full name (including aliases)
    • Date of birth
    • Residential and postal address
    • Telephone contact number/s – home, mobile and alternative
    • Medicare number (where eligible)
    • Name of the parent or caregiver (if appropriate)
    • Preferred language and interpreter requirements
    • Identifies as Aboriginal and/or Torres Strait Islander

    Referring practitioner details

    • Full name
    • Full address
    • Contact details – telephone, fax, email
    • Provider number
    • Date of referral
    • Signature

    Relevant clinical information about the condition

    • Presenting symptoms (evolution and duration)
    • Physical findings
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
    • Body mass index (BMI)
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
    • Current medications and dosages
    • Drug allergies
    • Alcohol, tobacco and other drugs use

    Reason for request

    • To establish a diagnosis
    • For treatment or intervention
    • For advice and management
    • For specialist to take over management
    • Reassurance for GP/second opinion
    • For a specified test/investigation the GP can't order, or the patient can't afford or access
    • Reassurance for the patient/family
    • For other reason (e.g. rapidly accelerating disease progression)
    • Clinical judgement indicates a referral for specialist review is necessary

    Clinical modifiers

    • Impact on employment
    • Impact on education
    • Impact on home
    • Impact on activities of daily living
    • Impact on ability to care for others
    • Impact on personal frailty or safety
    • Identifies as Aboriginal and/or Torres Strait Islander

    Other relevant information

    • Willingness to have surgery (where surgery is a likely intervention)
    • Choice to be treated as a public or private patient
    • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

  • If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

    • Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service.  Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
    • A change in patient circumstance (such as condition deteriorating or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
    • Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

Last updated: 5 May 2026

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