Nepean Community & Neighbourhood Services 
Close the Gap Program for Aboriginal and Torres Strait Islander People
REFERRAL FORM FOR SERVICE PROVIDERS
FAX TO (02) 4702 6139 
Email: ctg@nepeancommunity.org.au

The Close the Gap Program (CTG) is a free service which aims to improve and maintain a person’s health and wellbeing by providing support with the client and his/ her GP, linking to service providers to provide education for client to self-manage their health condition. Client’s with one or more of the following health conditions:
•	Cardiovascular Disease
•	Diabetes
•	Chronic Renal Disease 
•	Respiratory Disease
•	Cancer

Referrer’s Name:		
Organisation:	
	
Contact Details:	
	
Email:	

Referral Date: 	/ 	/ 	
Does the client Identify as:               Aboriginal □            Torres Strait Islander □           or Both □

Client’s consent: 
Family Name		Given Name		
Address: 			
Contact Number		D.O.B		
Medicare Card #		Expiry Date		
Health Care Card #			
Signature:			
GP Details:
Name:		Contact Number:		
Practice Name:	
	
Practice Address: 	

Support Required:	

	

Referral’s already completed to other Service providers: