Do NOT use this form to refer to ACAS, Aged Persons Mental Health, Early Supported Discharge,
Fast Track Ortho, Transition Care Program, Residential In Reach, GEM@Home or Community Health.
Community Access Unit ph. 9881 1100 Date of Referral: / /
Send this form by fax: 9881 1102 or email: sacs.integratedcare@easternhealth.org.au
Reason for Referral
Presenting problem or diagnosis and the impact on the client? What does the client need?
AMBULATORY CARE AND COMMUNITY
SERVICES REFERRAL FORM
Type or write legibly in black pen
Referrer’s name: Designation:
Location / Organisation: Phone:
Client is in hospital or HITH Yes No Discharge date: / / N/A
Hospital: Ward: Unit: Program
UR Number:
Surname:
Given Name:
Address:
Date of Birth: ________/________/_______ Sex: M F
Afx Hospital ID Label If Available – Internal use
Client Information
Interpreter required: Yes No If yes, preferred language:
GP details: Name: Phone:
Client address or temporary address
Name of carer(s) or NOK: Relationship:
Carer(s)/NOK Phones: Ph: Mobile:
To make appointment contact: Client or Carer(s)/NOK
Medical Information
Relevant history, medications or specialists: Home Oxygen
Infection Risk
Does the client have an NDIS Approved plan? Yes No
Does the client have a Home Care Package? Yes No
Level
Does the No advance care directive
client have? Presence of an advance care directive
Presence of a medical treatment decision maker
Presence of both an advance care directive alert and a medical treatment decision maker
Social and Community
Include current community services and relevant social situation.
Other concurrent referrals:
Client risks: Falls Pressure Care Medication
Allergies Living/Carer Situation
Cognition Malnutrition Likely to present to hospital Nil identied
Other
Strategies to manage risk:
Staff risks: Violence Behaviour Home Visit risk Drug & Alcohol Hoarding
Squalor Nil identied Other
Home Visit Risk completed Yes No EMR Alert Completed Yes No
Client is aware of referral and consents to receive requested service(s): Yes No
If no, provide details:
Client consents to sharing of relevant information as required Yes No
Client consents to receive information electronically (inc. SMS) Yes No
Email:
Client signature (if appropriate)
EH090240 AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM
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signature
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UR Number:
Surname:
Given Name:
Address:
Date of Birth: ________/________/_______ Sex: M F
Afx Hospital ID Label If Available – Internal use
Total number of pages in referral including attachments:
Referrer Name: Signature:
Rehabilitation
Community Rehabilitation Program
Client has experienced a change in function due to a recent acute
medical/health event and requires goal-directed rehabilitation.
R e q . D C s u m . D C s u m C P F
Occupational Therapy
Physiotherapy
• Priority Referral (likely to deteriorate and/or be readmitted if not seen
within 7 days). Please justify
Neuropsychology
Social Work
Dietetics
Speech Pathology
Client would benet from therapy in the following
setting:
Centre-based
Home-based
(please justify)
Focal Spasticity Management Clinic
Provides comprehensive medical assessment and recommendations
regarding the management of focal spasticity. Follow-up allied health
interventions are not organised in the clinic.
Chronic Disease Management
HARP (Hospital Admission Risk Program)
Client has a chronic health condition and/or psychosocial complexity
and requires care coordination to prevent hospital presentation.
Client or carer has potential to manage health conditions.
Cardiac
Diabetes
Psychosocial
Respiratory
Chronic Complex
Cardiac Rehabilitation
To assist people with cardiac conditions to return to an active and
fullling life.
Heart Failure Rehabilitation
To assist people with heart failure improve their knowledge and level
of functions
Pulmonary Rehabilitation
To improve the strength and exercise tolerance of people suffering
from a chronic respiratory conditions
Oncology Rehabilitation
To assist people with a primary diagnosis of cancer achieve their
maximum level of function
Specialist Clinics
Continence Clinic
Client requires assessment and management by geriatrician and/
or physio and/or nursing to address incontinence. Must be over
16 years old.
Falls and Balance Clinic
Client requires geriatrician PLUS physiotherapy & occupational
therapy assessment to determine cause of falls/poor balance and
to recommend falls prevention strategies.
CDAMS Cognitive Dementia and Memory
Service
Client requires comprehensive multidisciplinary assessment to
determine new diagnosis of possible/early dementia or related
conditions
Complex Care Clinic
Client requires geriatrician assessment of multiple aged related
medical conditions and/or requires diagnosis of cognitive changes
which have progressed beyond early stages.
Movement Disorders Program
Client has a diagnosis of Parkinson’s Disease or Parkinsonian
Disorder and requires multidisciplinary strategy training and/or
review by Neurologist and/or Clinical Nurse Consultant.
Ambulatory Pain Management Service
Client is ready to participate in active self-management of
chronic non-malignant pain including medication management
and allied health programs. Active TAC or WorkCover client
are ineligible. Client is aware that attendance at group Service
Orientation Session is required in most cases in order to access
the service
Rehabilitation Medicine Clinic
Rehabilitation Medicine is the medical specialty concerned with
the diagnosis, evaluation and treatment of patients with limited
function as a consequence of disease, injury, impairment and/or
disability.
Intensive Home-based Evaluation and
Management
Rapid Outreach Response (ROR)
Medium term intervention
Rapid response for older persons with high level complex
social or functional issues.
Development of relationship with the older person to enable
acceptance of required interventions and assistance.
Completion of an urgent ACAS assessment
Orientation Session is required in most cases in order to
access the service
AMBULATORY CARE AND COMMUNITY
SERVICES REFERRAL FORM
Type or write legibly in black pen
EH090240 AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM
Page 2 of 2 Version 4 Outdated forms may be returned. Current form located:
EH Intranet / Quick Links / CAMS / Ambulatory & Community Services / Ambulatory Care and Community Services Referral Forms
click to sign
signature
click to edit
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