Surname: ......
Given Names: ......
M.R.N.: ...... DOB: ......

COMMUNITY REHABILITATION SERVICE EXTERNAL REFERRAL FORM (TBA)

Use this form if client is not an inpatient or resident of Royal Rehab

Attach discharge summaries and copies of any screening/assessment tools

Date Referred: / Expected Discharge Date:
Clients Name: / Medicare No:
DOB: / COB: / Sex:
Address:
Phone Numbers:
Interpreter Required: Yes/No / Language:
Contact Person: / Relationship:
Phone Number: / Email address:
General Practitioner: / Phone:
Address:
Funding Source: Medicare [ ] LTCS [ ] DVA [ ] Workcover [ ] Private Health Fund [ ]
Insurer Name: / Claim/Membership No:
Relevant Medical Information (Please attach medical/admission/discharge/medication summaries)
Past Medical History:
Current Functional Status:
Physical Function (Please circle)
Self Care: Independent Assistance Required Equipment used:
Transfers: Independent Assistance Required Equipment used:
Mobility: Independent Assistance Required Equipment used:
Comments:

Surname: ......
Given Names: ......
M.R.N.: ...... DOB: ......

Communication issues: Yes/No If Yes, provide details:
Cognitive issues: Yes/No If Yes, provide details:
MMSE or RUDAS Score:
Social issues: Yes/No If Yes, provide details:
Service Referring to: Public OPD [ ] Private OPD [ ] Home Based Rehab [ ]
Please Tick services requested:
Dietitian [ ]
Neuropsychology [ ]
Nursing [ ]
Orthoptist [ ] / Occupational Therapy [ ]
Physiotherapy [ ]
Social Work [ ]
Speech Therapy [ ]
Aquatic Physiotherapy [ ]
Client Aware of Referral? / YES/NO / Urgent Referral? YES/NO
Drug/Alcohol Issues? YES/NO Challenging Behaviours? YES/NO Falls Risk: YES/NO
Comments:
Client Rehabilitation Goals:
Equipment Organised for Discharge (include source and length of loan if applicable):
Any Other Services Involved / Organised for Client (include contact details):
Referring Agency: / Name & Designation:
Phone number: / Contact email:
CRS Office Use Only
Date Received: / Date Admitted: / MRN:

Community Based Rehabilitation Service Ph: 9808 9687 Fax: 8415 7122

Outpatients Department Ph: 9808 9218 Fax: 8088 3895