Fillable AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM Type (Eastern Health Australia)

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AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM Type (Eastern Health Australia)

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The AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM Type (Eastern Health Australia) form is 3 pages long and contains:

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  • 52 check-boxes
  • 118 other fields

Country of origin: AUSTRALIA
File type: PDF

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Client Information
Surname: Given Name:
Sex: Male Female Other D.O.B: / / Confirmed Yes No
Mobile Number: Phone Number:
Medicare Number: ( ) Valid To: /
Is this a claim for: TAC VWA DVA Reference No.:
Does the client have an NDIS-Approved plan? Yes No
Does client identify as being of ATSI origin? Yes No
If yes: does the client agree to a referral to Eastern Health Aboriginal Services?
Yes No
If unknown:
Question unable to be asked or Client refused to answer
Does the client have?
No advance care directive 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
Interpreter required: Yes No If yes, preferred language:
Client’s Country of Birth:
Client’s living arrangement: With family With Others Alone
Usual accommodation: Independent Aged Care Residential SRS Other
Client’s usual address:
Client’s temporary address: (or NA )
Do NOT use this form to refer to ACAS, Aged Person Mental Health, Community Health, GEM@Home,
HARP, Residential Inreach, or Transition Care Program.
Send completed form to Eastern Health’s Community Access Unit via fax: 9881 1102
or email: sacs.integratedcare@easternhealth.org.au or phone enquiries to: 9881 1100
Reason for Referral
Presenting problem or diagnosis and the impact on the client?
What does the client need?
EH090250 AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM
Referrer’s name: Designation:
Location/Organisation:
Email: Phone No:
Referral Date: / / Est. Discharge Date: / /
Page 1 of 3 Version 6 Outdated forms may be returned. Current form located: www.easternhealth.org.au/health-professionals/gp-referral-templates
UR Number:
Surname:
Given Name:
Address:
Phone No. D.O.B: / / Sex: M F
Affix Hospital ID Label If Available – Internal use
AMBULATORY CARE AND COMMUNITY
SERVICES REFERRAL FORM
Type or write legibly in black pen
Client Information
Name of carer(s) or NOK:
Carer(s)/NOK Phones: Ph: Mobile:
To make appointment contact: Client or Carer(s)/NOK
Carer(s)/NOK availability Yes No
Carer residency status: Co-Resident Non-resident
GP Name: GP Phone:
GP Address:
Medical Information
Relevant history, medications or specialists: Home Oxygen
Infection Risk:
Weight-bearing Status:
(i) Additional Medical History: Attached
(ii) Additional Current Medications: Attached
Social and Community
Include current community services and relevant social situation.
Does the client have a Home Care Package? Yes
No
Level:
Other concurrent referrals:
Client risks: Falls Pressure Care Medication Allergies Living/Carer Situation
Cognition Malnutrition Likely to present to hospital Nil identified
Other
Strategies to manage risk:
Staff risks: Violence Behaviour Home Visit risk Drug & Alcohol Hoarding
Squalor Nil identified Other
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
Client signature (if appropriate)
Referrer’s signature Date: / /
EH090250 AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM
Page 2 of 3 Version 6 Outdated forms may be returned. Current form located: www.easternhealth.org.au/health-professionals/gp-referral-templates
UR Number:
Surname:
Given Name:
Address:
Phone No. D.O.B: / / Sex: M F
Affix Hospital ID Label If Available – Internal use
AMBULATORY CARE AND COMMUNITY
SERVICES REFERRAL FORM
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Chronic Disease Management
Cardiac Rehabilitation
To assist people with cardiac conditions to return to an active and
fulfilling 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
EH090250 AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM
UR Number:
Surname:
Given Name:
Address:
Phone No. D.O.B: / / Sex: M F
Affix Hospital ID Label If Available – Internal use
Rehabilitation
Community Rehabilitation Program
Client has experienced a change in function due to a recent acute
medical/health event and requires goal-directed rehabilitation.
Indicate profession(s) requested (req).
Discharge (DC) Summary is required and should be attached
Req. DC sum.
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 benefit 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.
SACS Specialist Clinics
GP referral or endorsement required
Continence Clinic
Client requires assessment and management by doctor 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 diagnose 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
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.
Page 3 of 3 Version 6 Outdated forms may be returned. Current form located: www.easternhealth.org.au/health-professionals/gp-referral-templates
AMBULATORY CARE AND COMMUNITY
SERVICES REFERRAL FORM
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AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM Type (Eastern Health Australia)

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Completed 8 February 2021

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