Referrals for Community-based services

Monash Health’s Community-based services support adults and children to improve and maintain health, independence and well-being within their communities.

Coordinating and providing integrated, multidisciplinary care across multiple settings we aim to empower clients to self-manage their health and health care in their own communities.

Working across the age spectrum, we support clients through all stages of non-acute care from prevention through to rehabilitation. Depending on the circumstances, services can be provided online, in-home, in community-based facilities and dedicated Monash Health Community Centres. Most services are time-limited and goal-directed, and offered one-to-one and in group settings and include clinical (eg: nursing, dental, medicine, physiotherapy, occupational and other therapies) and non-clinical (eg: counselling, community development, social work, case management) services.

External Referrers

Internal Monash Health Referrers

healthlink referrals for gp community health
healthlink referrals with number community health
email referrals community health
external referrals community health
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internal referrals community health

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Community Other QRGs

This page contains Quick Reference Guides for External and Internal referrals (above) and detailed referral guidelines and eligibility criteria on the following pages.

Please direct enquiries directly to the relevant program or contact the Community Acces team:

E: icareaccess@monashhealth.org

T: 03 857 25631

Search all services, departments and clinics

SpecialitySummary
Aboriginal Health – AdultThe Aboriginal Health Access and Support team provides support to Aboriginal and Torres Strait Islander people accessing care to maintain their health, wellbeing and independence. There is no charge for Aboriginal Health services. This includes: …
Aboriginal Health – PaediatricsHealthy Koori Kids is a service for Aboriginal children aged 0-17 years who are at risk of entering or are in out-of-home care. The service offers a multidisciplinary team comprising a Paediatrician, Paediatric Psychologist, Speech …
Cardiac Rehabilitation – AdultCardiac Rehabilitation is a program of support, exercise and education suitable for those recovering after a heart event, procedure or the diagnosis of a heart condition. It aims to assist in long term lifestyle changes …
Centre for Development and Disability Health (CDDH) – Adult CommunityThe Centre for Developmental Disability Health (CDDH) supports medical, disability sector and allied health professionals to provide healthcare to patients with intellectual and associated developmental disabilities through: Online clinical information and resources Online learning modules …
Cognitive Dementia and Memory Service (CDAMS)- AdultThe Cognitive Dementia and Memory service (CDAMS) is a multi-disciplinary, diagnostic clinic for older people experiencing change to memory or other areas of thinking. The clinic provides diagnosis, information, education, support and referral to other …
Community Health Nursing – Adults CommunityThe community nursing services available depend on the age of the client. Click below for more information on the services available. Community Health Nursing (18 to 65 years) Introduction Community Health Nursing is part of …
Community Rehabilitation (Home and Centre based) – AdultCommunity Rehabilitation offers short-term goal-directed rehabilitation aimed at improving a client’s function and independence following a change in function due to recent acute medical / health event. The multidisciplinary team approach offers home and centre-based …
Complex Biopsychosocial Needs – AdultComplex Care is a multi-disciplinary team (Nursing, Allied Health and Medical) that provides a comprehensive approach to assisting people with chronic disease and/or complex psychosocial issues by: Facilitating access to short term responsive care coordination …
Continence – AdultThe Continence Clinic is a specialist service with a multi-disciplinary approach to the management and treatment of bladder and bowel issues including; urinary and faecal incontinence, urinary and faecal urgency, frequency, constipation and or pelvic …
Counselling – Adult CommunityCounselling provides professional assistance and guidance to assist clients to resolve personal or psychological issues, support making changes in life and fostering wellbeing. Counsellors provide help with issues such as anxiety, depression, stress and grief. …
Counselling – Paediatrics CommunityThe counselling team offer counselling and therapy to children, teenagers, families and carers. They have the experience to assist, understand and develop skills in the areas of: counselling for children 0-14 years old with anxiety, …
Diabetes Dietetics – Adult CommunityDietitians provide nutrition information, diabetes management and education services to adults. Services are provided for people requiring therapeutic input for (but not limited to): overweight and obesity malnutrition / Loss of weight / Loss of …
Diabetes Education – Adult CommunityDiabetes Nurse Educators and Dieticians provide: diabetes self-management support nutrition and dietary support understanding of medications and insulin therapy exercise and managing hypoglycaemia Services are centre-based. Eligibility Criteria Adults over 18 years old who: attend …
Dietetics – Adult CommunityDietitians provide nutrition information, Diabetes management and education services to adults. Services for people requiring therapeutic input for (but not limited to): Overweight and obesity Malnutrition / Loss of weight / Loss of appetite People …
Dietetics – Paediatrics CommunityDietitians work with babies, toddlers and children who are having difficulties with a variety of nutritional concerns. Dietitians also work in Feeding Clinics with Speech Pathologists, Social Workers and Psychologists. Dietitians can see children for: …
Exercise Physiology – Adult CommunityExercise Physiologists provide exercise rehabilitation, lifestyle modification, disease prevention and management service as part of re-establishing and sustaining the functional independence of our clients. Some of the services offered include: comprehensive assessments cardiovascular reconditioning functional …
Exercise Physiology – Paediatrics CommunityPaediatric Exercise Physiologists work with children and their families. They design lifestyle and exercise programs, or implement health and wellbeing interventions/strategies, that cater to the child’s needs taking into account their age, growth and development. …
Falls and Balance Clinic – AdultThe Falls and Balance Clinic is an assessment-only specialist multidisciplinary clinic ​for people who are experiencing issues with falls, balance and dizziness, affecting their mobility particularly when the reason or cause of the problem is …
Feeding Clinic – Paediatrics CommunityThe Feeding Clinic provides support to infants and young children where there are concerns about growth and the development of feeding skills including: faltering growth/poor weight gain low birth weight history of enteral feeding difficulties …
Gait Clinic – Paediatrics CommunityThe Gait Clinic is a joint Physiotherapy/Podiatry appointment for infants, children and adolescents who have developmental, neurological or orthopaedic needs related to their lower limbs. The clinic assesses and manages: developmental concerns around walking, running, …
Healthy Mothers Healthy Babies – Paediatrics CommunityHealthy Mothers Healthy Babies is an outreach program for pregnant women experiencing challenges which may impact the health, social and emotional wellbeing of themselves, their unborn baby or family. Services include: accessing pregnancy care birth …
Heart Failure (CHF) Support and Management – Adult CommunityThe Chronic Heart Failure (CHF) program works in partnership with GPs to support their clients within the community. The program aims to prevent hospital admissions and improve quality of life through self-management education support delivered …
Movement Disorders Clinic – AdultThe Movement Disorder Clinic is a specialist clinic with a multidisciplinary approach to the management and treatment of Parkinson’s disease, Multi Systems Atrophy, Progressive Supranuclear Palsy and other related movement disorders. The holistic clinic consists …
Multidisciplinary Centre Nursing (MDC) – Adult/PaediatricCommunity-based (Multi Disciplinary Centre) Nurses provide services to clients who have experienced sexual assault or family violence, and their non-offending family members. Nurses work closely with MDC stakeholders, including Police, Child Protection and Counsellors. There …
National Disability Insurance Scheme (NDIS) – Adult CommunityThe Adult NDIS team offers adult participants (18-65 years) with an active NDIS plan the following services: Dietetics Speech Pathology Occupational Therapy Care Coordination Eligibility Criteria A current NDIS Plan listing the appropriate supports is …
National Disability Insurance Scheme (NDIS) – Paediatric CommunityThe Paediatric NDIS team offers the following ECIA and NDIS Services for 0-17 year olds with an active NDIS plan: Dietetics Speech Pathology Occupational Therapy Physiotherapy Podiatry Exercise Physiology Feeding Clinic Support Coordination Eligibility Criteria …
Occupational Therapy – Adult CommunityAdult Occupational Therapy assists people and carers whose lives are impacted by ill-health or frailty, to live fulfilling and healthy lives safely in their own home environment. Community-based Occupational Therapy offers: Assessment of daily living. …
Occupational Therapy – Paediatrics CommunityOccupational therapists work with children, their families and community to develop functional skills in order to help them participate and engage better in their home, school/kinder and community. Focussing on key areas such as developing …
Pain Management Service – Adult The Pain Management Clinic is a multidisciplinary and interdisciplinary outpatient service to patients with a diagnosis of persistent (chronic) pain > 3 months duration. Services provided include: education comprehensive assessment intervention rehabilitation Eligibility Criteria All …
Physiotherapy – Adult CommunityCommunity Health Physiotherapy provides services as part of an interdisciplinary team for frail older people, younger people aged 18-65 with a disability or long-term impairment. We also support carers. We provide: Individual assessment and treatment …
Physiotherapy – Paediatrics CommunityPaediatric Physiotherapy aims to improve function and independence for infants, children and adolescents who have developmental, respiratory, neurological or orthopaedic needs using age-appropriate, evidence-based therapy and family focussed practices. Paediatric Physiotherapy helps manage or improve: …
Podiatry – Adult CommunityPodiatrists deal with the prevention, diagnosis, treatment and rehabilitation of medical and surgical conditions of the feet and lower limbs. Conditions treated include those resulting from bone and joint disorders, soft-tissue and muscular pathologies as …
Podiatry – Paediatrics CommunityPodiatrists care for feet and ankles through exercise, orthotics and footwear. Podiatrists work with babies, toddlers, children and adolescents on: prevention, diagnosis, treatment and rehabilitation of medical and surgical conditions of the feet and lower …
Post Acute Care – Adult CommunityPost Acute Care (PAC) provides community-based services /home-based treatment and support to help patients recover at home after leaving hospital. It aims to assist people especially if they live alone, have limited support or if …
Psychology – Adult CommunityPsychologists provide professional assistance and guidance to assist clients to resolve personal or psychological issues, support making changes in life and fostering wellbeing. They provide help with issues such as anxiety, depression, stress and grief. …
Psychology – Paediatrics CommunityPsychologists in the program work with children aged 0 -14 years of age and their families to provide assessments and interventions for a range of concerns including: child anxiety and depression behavioural and developmental issues …
Pulmonary – Adult RehabilitationPulmonary Rehabilitation is suitable for those who have lung disease or are limited by breathlessness. The service sees clients with chronic lung disease at all stages of their condition – from mild to severe. Clients …
Refugee Health and Wellbeing – Adult CommunityMonash Health Refugee Health and Wellbeing service provides comprehensive primary care services together with tertiary services including infectious diseases, paediatrics and psychiatry. A Refugee Health Nurse on Triage service is also available daily to support …
Refugee Health and Wellbeing – Paediatric CommunityMonash Health Refugee Health and Wellbeing provides a paediatric tertiary referral medical service for children aged 0-17 years presenting with a range of health issues including: General and developmental/behavioural paediatrics Latent TB infection Infectious diseases …
Respiratory Support and Management – Adult CommunityThe Chronic Respiratory program works in partnership with GPs to support their clients within the community. The program aims to prevent hospital admissions and improve quality of life through self-management education support delivered by clinical …
Sexual and Reproductive Health – Adult/PaediatricSexual Health clinics at Cranbourne and Dandenong focus on sexual and reproductive health information and breast health information. All services are inclusive of psycho-social support, mental health screenings / assessment, general health and assistance with …
Social Support – Adult CommunityThis program supports an individual’s ability to remain independent and living in the community by providing enjoyable and meaningful activities to support social inclusion and community participation. The program helps to: keep the client independent …
Social Work – Adult CommunityAs part of multi-disciplinary teams, Social Workers assist clients, their families and carers with services including: Psychosocial assessments Crisis intervention Counselling Family support/carer support Care coordination Access and liaison to community services Bereavement support Advocacy …
Social Work – Paediatrics CommunityInternal Referrals Only: Children must be engaged in support with another service(s) within the Child and Family Program to be referred. Social Workers and Family Support Workers assist children 0-17 years and families with psychosocial support …
South East Centre Against Sexual AssaultSECASA is a specialist sexual assault and family violence service, which provides: Time-limited therapeutic interventions and counselling following sexual assault and/or family violence, to victim/survivors and other affected family members 24/7 sexual assault crisis response …
Speech Pathology – Adult CommunitySpeech Pathologists provide centre-based and home-based services to people over 18 years of age living with chronic conditions or disability who are experiencing loss of function, personal confidence and independence due to impairment of communication …
Speech Pathology – Paediatrics CommunitySpeech Pathologists work with babies, toddlers and preschool children who are having difficulties in the development of their communication and/or feeding skills including: language difficulties speech difficulties dysfluency or stuttering feeding issues assessment and therapy …
Youth Services – Adult/PaediatricYouth services are in an interdisciplinary team who offer: Exercise Physiology Music Therapy Care Coordination Community Health Nursing Dietitics Counselling Speech Therapy Services include and after- school hours ‘Youth Health Hub’ program at the Monash …