Are You of Aboriginal Or Torres Strait Islander Origin? No

Form D205

Hearing Services Referralv4.0

Office Use Only
UR No: / Re New Urgency: Cat 1E Cat 1M Cat 2 Cat 3 Cat 4
Allocated to: / 301(Group/1:1) 602 (IR) DVA Job Access NDIS
Appointment date / time: / HRR HV Scheduled by:
Personal Details Date:
Surname: / Other names:
Date of birth: / Male Female
Address:
Postcode:
Phone Number: / Mobile:
Work Number: / Email:
TTY: / Fax:
Country of birth: / Language preferred:
Interpreter required? Yes No
Who is the contact person for appointments? ClientKey contact person (provide details below)
Key Contact Details
Name: / Relationship:
Phone: / Mobile:
Referral Source: / Self / Family member / External agency
If you are referring this client, please complete the following:
Name: / Organisation:
Phone: / Email:
Is the client aware of this referral? / Yes No

Form D205

Hearing Services Referral v4.0

Are you of Aboriginal or Torres Strait Islander origin? No

Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander

Correspondence: Telephone SMS Email Standard print Large print Braille

Employment status: / Marital status:
Pension/benefit (type):
My Aged Care: No Yes
DVA: No Yes Card Type: Gold White (Hearing) DVA Number:
How did you hear about our services?
About Your Hearing
Do you have: Hearing loss Auditory Processing Disorder Unsure
Have you had your hearing tested? / Yes No / DDate:
Hearing tested by: / Audiologist Ear, Nose and Throat Specialist GP Other
Name (if known):
Are hearing aids used? Yes No Sometimes

Referral Details

Requires assistance with / reason for referral (please include any relevant mobility, access or communication needs):

Please forward the completed form to:
Guide Dogs SA/NT - Hearing Services
251 Morphett Street
Adelaide SA 5000 / Phone: (08) 8203 8394
Fax: (08) 8203 8332
Email:

Form D205

Hearing Services Referral v4.0

Risk Assessment – to be completed for all home or off-site visits – Internal Use Only

Does the client have any hesitations/concerns in allowing this service into their home?

Yes No

If installing electrical devices, is there a suitable RCD device fitted?

Yes No

Is there anything in regard to the client/others/household/pets that might be a potential risk to anyone visiting the home?

If yes, can risk be managed? i.e., pet removed from the room.

Yes No

Are any other people expected to be present at the time of the visit/service?

Yes No

Are there any special directions needed to get to the clients home?

Yes No

Is there any difficulty accessing the premises i.e. stairs, steep driveways?

Yes No

Will there be a problem for the referred person / carer to answer the door?

Yes No

If the client is a smoker, do they object to not smoking during visits?

Yes No

Are there any other alerts or potential risk to staff which you are aware of?

Yes No

If the answer was yes or unknown to any of the questions above please provide further explanation:

Associated Policies and Procedures: / A3 Risk Management Policy
B48 Personal Information Handling Policy
M307 Risk Management Framework
C585 Referral and Allocation of Hearing Services Procedure
M159 Hearing Services Manual
References:
Uncontrolled when printed / Next Revision Due: 20 January 2018
guidedogs.org.au / Page 1 of 3