TOOL 14. Referral Card and Referral Monitoring Form

TOOL 14. Referral card and referral monitoring form

Referral card

Date referred:
UIC / Referred by (A4) / Referred to (code) / Service requested (E)

Monthly monitoring form for referrals

Date referred / UIC / Service requested (code from E):
Referral results
(check one): / □Person never came to referral site
□Person came to referral site – doesn’t need to return
□ Person came to referral site – needs to return
□Person came –referred elsewhere / Date seen: ______
Date referred: ______

Instructions for referral card and referral monitoring form

Referral card
This form is used to track a person who has been referred. The referred person should provide this card to the referral site upon arrival.
UIC / Write in unique identifier code for referred person: See B1.
Referred by (A4) / Write in the service delivery provider code.
Referred to (code) / Write in the code for the site to which the person is referred.
Service requested (E) / Write in the code of the service requested from section E. For example, if the person is being referred for legal counselling, write “E17.”
Monthly referral monitoring form
This form is used report on the outcome of a referral on a monthly basis.
Date referred / Write in the date when the person was referred to your site.
UIC / Write in unique identifier code for referred person: See B1.
Service requested (code from E): / Write in the code of the service requested from section E. For example, if the person has been referred for legal counselling, write “E17.”
Referral results
(check one): / Check one of the following options to record what happened to the person who was referred for a service.
Person never came to referral site / Check this box if the referred person never came to the site.
Person came to referral site – doesn’t need to return / Date seen: / Check this box if the person came and received services. This box should be checked in a situation where the person only needed to come to the referral site one time. For example, if the person came for abscess care and prevention (E3), received treatment, and does not need to return – check this box. Additionally, write in the date the referred person was seen.
Person came to referral site – needs to return / Check this box if the person came and received services, but needs to return to complete the referral. For example, if the person was referred to the site for mental health counselling, it is likely that he/she will need to come back for subsequent sessions. In that case, check this box.
Person came –referred elsewhere / Date referred: / Check this box if the person came to the referral site, but the services he/she was referred for were not available at that time. Check this box if it was necessary to refer the person elsewhere so that he/she could get the services sought. Write in the date the person was referred.
Reference: