Domiciliary Care Office Use CME No: EPISODE NO:

Domiciliary Care Referral Form

Details of person being referred

Title: Mr Mrs Miss Ms Other:

Surname:

Given name(s):

Preferred name(s):

Sex: 1 Male 2 Female 9 Not stated DOB: / / Estimate Age:

Usual Address:

Postcode:

Postal Address:

Postcode:

Phone (Home):

Marital status

1 Never married 2 Widowed 3 Divorced

4 Separated 5 Married/Defacto 9 Not known

Accommodation setting

1 Home Owner / 2 Private Rental / 3 Public Rental
5 ILU / 6 Boarding House

19 Other

Pension Type:

Pension Number

Health insurance / Yes / No / Unknown
Extras
Ambulance Cover / Yes
Yes / No
No / Unknown
Unknown
Compensable / Yes / No / Unknown

Country of birth

Indigenous status 9 Not stated

1 Aboriginal, not TSI 2 TSI, not Aboriginal

3 Both 4 Neither Aboriginal, nor TSI

Primary language

Interpreter required Yes No unknown

If Yes, details

Carer Availability

1 Has a carer 2 Has no carer 9 Not stated

Carer Relationship

1 Wife/Female Partner 2 Husband/Male Partner

3 Mother 4 Father

5 Daughter 6 Son

7 Daughter-in-law 8 Son-in-law

9 Other Relative – Female 10 Other Relative – Male 11 Friend/Neigh – Female 12 Friend/Neigh – Male

Date of Referral: / /

Carer Residency

1 Co-Resident 2 Non-Resident 9 Not stated

Usual Living Arrangements

1 Lives alone 2 Lives with Family

3 Lives with others 9 Not stated

Details of person making referral to Domiciliary Care

Name:

Organisation:

Program Name:

Relationship to person being referred:

Phone:

Client aware of referral consenting to referral: Yes No

If No, reason client unaware:

If referred by hospital:

Ward No:

Admission Date: Discharge date:

Contact person for the client being referred

Name:…………......

Is this person the client’s carer? Yes No Is this person nominated to be at assessment? Yes No Does this person reside with the client? Yes No If no, Address:

Phone (Home):

Phone (Work):

Mobile:

E-mail:

Relationship to client

1 Spouse/Partner 2 Daughter/Son 3 Parent

4 Sibling / 5 Other Relative / 6 Friend
8 Not stated / 9 Other

Comments:

GP Details

Name:

Address:

Phone: Fax:

E-mail:.

Domiciliary Care Office Use CME No: EPISODE NO:

Client Name: Date of Birth: / /

Diagnoses/ Past Medical History:

Referral Request:

Presenting Problems/Issues:

Current Services

Service Type / Organisation/Contact Details

Notification of Referral

Do you require notification of the outcome of the referral: Yes No If yes, please indicate your preferred method of contact:

Fax

Email