Date of Birth: ________/________/_______ Sex: M F
Afx Hospital ID Label If Available – Internal use
Total number of pages in referral including attachments:
Referrer Name: Signature:
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
• Priority Referral (likely to deteriorate and/or be readmitted if not seen
within 7 days). Please justify
Client would benet from therapy in the following
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.
To assist people with cardiac conditions to return to an active and
Heart Failure Rehabilitation
To assist people with heart failure improve their knowledge and level
To improve the strength and exercise tolerance of people suffering
from a chronic respiratory conditions
To assist people with a primary diagnosis of cancer achieve their
maximum level of function
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
Client requires comprehensive multidisciplinary assessment to
determine new diagnosis of possible/early dementia or related
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
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
Intensive Home-based Evaluation and
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
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