Client Information
Surname: GivenName:
Sex: Male Female Other  D.O.B: //ConrmedYes No
MobileNumber: PhoneNumber:
MedicareNumber: ()
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PersonsMentalHealth,TransitionCareProgram,
Residential-In-Reach,GEM@HomeorCommunityHealth.
CommunityAccessUnit–ph.98811100
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?
URNumber:
Surname:
GivenName:
Address:
DateofBirth:________/________/_______Sex: M F
AfxHospitalIDLabelIfAvailable–Internaluse
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Page1of3Version5Outdatedformsmaybereturned.Currentformlocated:www.easternhealth.org.au/health-professionals/gp-referral-templates
AMBULATORY CARE AND COMMUNITY
SERVICES REFERRAL FORM
Typeorwritelegiblyinblackpen
URNumber:
Surname:
GivenName:
Address:
DateofBirth:________/________/_______Sex: M F
AfxHospitalIDLabelIfAvailable–Internaluse
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identied
Other
Strategiestomanagerisk:
Staffrisks: Violence Behaviour HomeVisitrisk Drug&Alcohol Hoarding 
Squalor Nilidentied 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5Outdatedformsmaybereturned.Currentformlocated:www.easternhealth.org.au/health-professionals/gp-referral-templates
AMBULATORY CARE AND COMMUNITY
SERVICES REFERRAL FORM
Typeorwritelegiblyinblackpen
click to sign
signature
click to edit
click to sign
signature
click to edit
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
EH090250 AMBULATORY CARE AND COMMUNITY SERVICES REFERRAL FORM
URNumber:
Surname:
GivenName:
Address:
DateofBirth:________/________/_______Sex: M F
Afx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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.
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
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.
Page3of3Version5Outdatedformsmaybereturned.Currentformlocated:www.easternhealth.org.au/health-professionals/gp-referral-templates
AMBULATORY CARE AND COMMUNITY
SERVICES REFERRAL FORM
Typeorwritelegiblyinblackpen
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