REFERRAL
DOMICILIARY THERAPY CRITERIA
Client is eligible if housebound and lives in Boroondara, Yarra or
lower part of Darebin, south of Dundas St..
Client is not eligible if has a DVA gold card or EACH package, or lives in a hostel or
nursing home, or is able to access community rehabilitation/health centres.
Domiciliary Therapy
Phone: 9816 0529
Referrer Details
Referrer Name
Relationship/Service
Contact (to make first visit arrangements)
Client Details
Surname
Address
Suburb
Present Location
Phone Number
Date of Birth
Fax: 9816 0515
Date of Referral
Referrer Phone
Referrer/Intake Worker Signature
Given Names
Postcode
Marital status
Religion
Sex
Indigenous Status (specify if Aboriginal and/or Torres Strait Islander)
Country of Birth
Interpreter required
Guardian or EPOA
Service/s Requested
Physiotherapy
Podiatry
Client/Carer Agreeable to Referral
Reason for Referral
Language spoken
no
yes
no
yes
Occupational Therapy
yes
no
If yes, please specify
Dietetics
Speech Therapy
Brief Medical History
1/1/08
LMO Details
LMO Name
LMO Address
Phone
Fax
Case Management Details
Community Package Type
Organisation
Case Manager Name
Case Manager Mob
Linkages
CACPS
Phone
Fax
Income Source & Medicare Details
Pension (Age/disability/Carer) specify:
Veteran Affairs (white only, gold not eligible)
Self funded (tick if yes)
Medicare Card No.
Living Arrangements & Accommodation
Accommodation setting (own/rent/MOH/SRS/ILU)
Pension No
DVA No
Expiry
Position
Expiry
Living arrangements (alone/family/others)
Safety Issues (behaviour, aggression, house, manual handling, alcohol, drugs, firearms)
Next of Kin Details (If not carer. Carer details below)
Surname
Relationship
Given Names
Phone
Carer information if known
Carer Information (unpaid, regular & sustained help)
Has a carer
Carer Surname
Relationship
Address (if known)
Suburb
Phone Number
Date of Birth
Preferred Language
Country of Birth
No carer
Carer is caring for more than 1 person (not healthy children)
Given Names
Postcode
Mob
Age estimate
Sex
Indigenous status
Dom staff only
Initial Visit Date:
No Initial Visit
Reason No Initial Visit:
One off
Ongoing
Staff initials:
Initial Visit Date:
No Initial Visit
Reason No Initial Visit:
One off
Ongoing
Staff initials:
Initial Visit Date
No Initial Visit
Reason No Initial Visit:
One off
Ongoing
Staff initials
Office Use only
Admit-partial
date:
Client letter
Referrer letter
GP letter
Admin stats
Review
date:
Admit-complete
date:
1/1/08