RECREATIONAL RESPITE REFERRAL

Page 1 of5 ONCALL FORM

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SUMMARY INFORMATION
Carer Name: / Care Recipient Name:
PERSON COMPLETING THIS APPLICATION
Agency Service Provider Case Manager
Name: / Position:
Organisation: / Phone:
Fax: / Email:
Confidential / Doc Version 6
Last Updated 21/102016
FilePath://CSW – Rec Respite Application Form.doc

RECREATIONAL RESPITE REFERRAL

Page 1 of5 ONCALL FORM

CARER INFORMATION
CarerName: / DOB:
Address:
Suburb: / Postcode: / State:
LGA: / Work/Home Phone: / Mobile Phone:
Confidential / Doc Version 6
Last Updated 21/102016
FilePath://CSW – Rec Respite Application Form.doc

RECREATIONAL RESPITE REFERRAL

Page 1 of5 ONCALL FORM

Relationship to Care Recipient: / Gender: M F
Ethnic Origin: Aboriginal Aboriginal & TSI Non-Indigenious Torres Strait Islander
Confidential / Doc Version 6
Last Updated 21/102016
FilePath://CSW – Rec Respite Application Form.doc

RECREATIONAL RESPITE REFERRAL

Page 1 of5 ONCALL FORM

CARE RECIPIENT INFORMATION
Care Recipient Name: / DOB:
Address:
Suburb: / Postcode: / State:
LGA: / Work/Home Phone: / Mobile Phone:
Relationship to Carer: / Gender: M F
Ethnic Origin: Aboriginal Aboriginal & TSI Non-Indigenious Torres Strait Islander
What are the care recipients likes and interests:
ELIGIBILITY (All Criteria Must Be Met)
CARER / The person providing support usually lives in the Southern Region. / Yes No
The carer’s role must be ongoing or likely to be ongoing for at least 6 months, or less where the person being supported needs palliative care. / Yes No
A person who provides regular and sustained care and assistance to a dependant family member or friend without payment. / Yes No
CARE RECIPIENT (Select all that apply and provide detail)
HIGH MEDICAL NEEDS:
(Please outline the details below and complete the Care Recipient profile to provide further information)
HIGH PHYSICAL NEEDS:
(Please outline the details below and complete the Care Recipient profile to provide further information)
CHALLENGING BEHAVIOUR
(Please outline the details below and complete the Care Recipient profile to provide further information)
CARE RECIPIENT DIAGNOSES
Indicate which the care recipient has been diagnosed with: (select all that apply)
Intellectual disability Autism Spectrum Disorder
Physical disabilityAcquired brain injury
Neurological disabilityDeafblind (dual disability)
Vision impairedHearing impaired
Speech impairedMental health (give details below)
Provide details and list any disabilities not already included above:
RESPITE HISTORY (for carer and care recipient)
Had the carer/care recipient accessed respite previously? / Yes No
Type of respite accessed / Service Name / Comments: (what worked, issues, important respite feature)
After School Care /
School Holiday Program
Day Program
Community Activities
In-Home
Recreation (camps,
weekends, activities)
Other
How would the carer like to use their respite time? (note supports required to achieve this)
SUPPORTS
Emergency Contact Name/s / Phone Number / Relationship
Agency Name / Case Manager / Phone Number BH and AH
Comments:
CARE RECIPIENT DAILY LIVING DETAILS
What does the CR need assistance with? What support does the carer provide?
(I = Independent A = Assistance [includes prompting and supervision] FA = Full Assistance N/A = Not Applicable)
Care Recipient First Name: / Last Name:
ACTIVITY I A FA N/A
Self care / Washing
Drying
Dressing
Eating / Special Diet Aids Required PEG Tube
Allergies / Intolerances:
Toileting / Urinary Incontinence Faecal Incontinence
Details of toileting regime, aids used (pads, kylie sheet, commode):
Mobility/
Transfers / Risk of Falls Transfers Required Hoist In Use
Aids & Equipment:
Sleep / Disturbances at Night (frequency, reason, required response):
Sleeps During the Day:
Administering of Medication / Webster Pack Dosette Original Packaging
Medication chart required Yes No
Cognition / Memory problems Thinking & Reasoning Problems
Difficulties with Problem Solving Problems with Judgement
Communication / Hearing aids Vision aids Speech impairment Expressive language impairment Comprehension difficulties
Driving/
Transport / Rate Care Recipients’ sense of road safety
Good Average Poor
List any issues when travelling in a vehicle (i.e. removes seatbelts, bangs on windows, needs to sit in a particular position in the car)
Comments:
COMMUICATION REQUIREMENTS
Indicate the preferred communication style of the care recipient
(Select all that apply)
Are there Behaviours of Concern? Yes No
Verbal
Non-Verbal / Gestures
Sign language / Makaton / Compic images
Other communication aid (specify below)
Other Communication Aid / Details:
CARE RECIPIENT BEHAVIOUR DETAILS
Are there Behaviours of Concern? Yes No
Agitated / Self Harm / Wandering / Absonding / Resistance
Sexually Inappropriate / Noisy / Verbal / Physical Aggression
Hallucinations / Delusions / Impulse control / Paranoia
If any of the above have been indicated, please attach a Behaviour Managmenet Plan
MEDICAL CONSIDERATIONS
Give details for any medical or health conditions for the care recipient:
AsthmaEpilepsy
DiabetesOther (specify below)
Other Medical/Health Conditions:
If any of the above have been indicated, please attach a Medical Managmenet Plan
DISABILITY ASSESSMENTS
DHHS / Done
Pending / Date: / By: / Outcome:
NDIS / Done
Pending / Date: / By: / Outcome:
Other / Date: / By: / Outcome:
Confidential / Doc Version 6
Last Updated 21/102016
FilePath://CSW – Rec Respite Application Form.doc