Meath Adult Disability Service
Referral Form
Personal Details:
Clients Name: ______Male Female
Address:______Date of Birth: ______
______Phone No: ______
______Mobile No: ______
______E-Mail: ______
Nationality: ______First Language: ______
Medical Card: Yes NoNumber: ______
Long Term Illness Card:Yes No Number: ______
Registered on National Disability Database:
Yes No Don’t Know Database Number:______
Primary Carer (if applicable): ______
Relationship to Client: ______Phone No:______
Details of Disability:Diagnosis and brief background
______
______
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OFFICE USE ONLY:
Received By Project Manager: ______Date: ______
Allocatedto Team Member:______Date: ______
Notsuitableforservice:______Date: ______
Returnedto: ______Date: ______
Referredonto:______Date: ______
Moreinformationisrequired:______Date: ______
The Client is currently living…….
Alone / with Spouse/Partner / with Children / Number of Children _____with Relatives / with Friends/Flat mates / in Residential Service
Other: (Please Specify) ______
Is the Client currently accessing any of the following Services?
General Practitioner (GP) Yes No: / Name: ______Address: ______
Occupational Therapy: Yes No: / Therapist: ______
Address: ______
Physiotherapy: Yes No: / Therapist: ______
Address: ______
Public Health Nurse
/ Liaison Nurse: Yes No: / Name: ______
Address: ______
Social Work: Yes No: / Name: ______
Address:______
SpeechLanguage Therapy:Yes No: / Therapist:______
Address:______
Home Support: Yes No: / Supplied by: ______
Respite: Yes No: / Where: ______
Day Service / School: Yes No: / Where: ______
Please name any other Services/Agencies the Client may have used in the past:
______
______
______
______
______
______
Reason for Referral: What services are needed and why they are needed?
Note: Please note that Social Work Services are available through Meath Primary Care Services and a Referral Form for this service is available at HSE Meath PCCC, Child & Family Centre, Navan, Co. Meath, Tel: 046-9078861.
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______
______
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Details of Person making Referral: If this is not a self-referral
Name of Person Referring: ______Contact No: ______
BLOCK CAPITALS
Address: ______
Please state your Involvement/Relationship with the Client: ______
______
Is the Client aware of the Referral?Yes No
If No, state reasons why: ______
______
Signature: ______Date of Referral: ______
Meath Disability Service staff work in a multidisciplinary/interagency fashion.
So that we all work together to help you we may need to share information
about you. We will only ever use or pass on information if others involved in
your care have a genuine need for it. This will usually be when we refer to
another service (for example; a specialist) or to keep others involved in your
care informed about your progress. We are careful to share only the clinical
information that is necessary to provide you with the best care, such as your
diagnosis, relevant past medical history, treatment details and progress made
against your care plan etc. Any one who receives information from us is also
under a legal duty to keep it confidential
Signature of Applicant:______Date: ______
Signature of behalf of: ______Date: ______
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Please attach all other relevant information e.g. Assessments, Reports, Letters.
Incomplete forms will be returned.
Return completed form to:The Coordinator,
Meath Adult Disability Service
HSE,
Beechmount Community Team Office,
BeechmountHomePark,
Navan,
Co. Meath.