Bradma
Transition Care Program Referral Form
Bed Based
Community Based
Reason/s for referral:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
TCP goals:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Patient/family goals/expectations:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Section 1: Referral Source/ Information:
External Referral – Health Network:
Internal Referral
Referrer:
Referral Date:
Contact details:
Referral Reason:
Patient Location/ Ward Ph:
Treating Team/Reg Pager:
Admission Date:
ACAS Approval:
Yes
Approved For:
Permanent Care
Delegation Date:
/
No
/
Respite Care- High/Low
Flexible Care
Home Care Package Level:
ACCR Lapsing date:
Discharge Destination (If Known):
Section 2A: Client Details:
Marital Status:
Country of Birth:
Language/s spoken:
Interpreter needed/ not needed (please Circle)
Pension No:
Pension Type:
Medicare No:
Medicare Expiry:
DVA No:
DVA Card Colour:
GP Name:
GP Contact Details:
Gold
White
Blue
Section 2B NOK/ VCAT/ EPOA Details:
NOK (1): Mr/Mrs/Ms/Miss
Relation to Client:
NOK Address:
NOK Ph: (Home)
(Work)
NOK (2): Mr/Mrs/Ms/Miss
(mobile)
Relation to Client:
NOK Address:
NOK Ph: (Home)
(Work)
(mobile)
VCAT/ EPOA
VCAT Application Submitted:
Applicant Details
Yes
No
Application for Guardianship/ Administration/Both
Name:
Address:
Date Submitted:
Ph:
Hearing Date (If Known):
EPOA/ Administrator:
Yes
No
Name:
Ph:
Medical EPOA:
Yes
No
Name:
Ph:
Guardian:
Yes
No
Name:
Ph:
Advanced Care Plan
Yes
No
Details:
Section 3: Medical Information:
History of
Presentation:
Past Medical History:
Ongoing Active
Medical/Surgical
Issues:
Follow up plans/
Appointments:
Orange
Care requirements:
Bariatric equipment required: ___________________________________________________
______________________________________________________________________________
NWB UL: Duration of NWB :_________________ Ortho review date:____________________
NWB LL: Duration of NWB :_________________ Ortho review date:____________________
VRE+ / MRSA: Location of infection: _____________________________________________
Contact Precautions/ Details: ___________________________________________________
Wounds: Location of wound:____________________________________________________
Dressing Regime/ Frequency:___________________________________________________
Other (Please specify below)
Section 4: Social, Functional and Cognitive Information:
Current Psychosocial Situation:
Lives alone
Lives with Spouse/ Family/ Others:
Accommodation Type:
House
Accommodation Owner:
Unit/ Flat
Client owned
Facility:
Family owned
Other:
Private Rental
Other:
Main Social Supports:
HACC Services/ Frequency:
Home Care Package:
Yes
No Package Details (level and services):
Case Manager:
Yes
No Details:
Financial Issues:
Yes
No Details:
Legal Issues:
Yes
No Details:
Pre-morbid
Mobility
(eg: ambulation including
distance/gait aid, transfers,
falls history, endurance)
Occupational Performance
(eg: Personal care, toileting,
domestic and community
occupations)
Cognition:
(eg: cognitive impairment/
delirium/ dementia diagnosis,
MMSE/ RUDAS Score)
Current
Ongoing Goals
Communication
(eg NESB, need for
interpreter non-verbal,
expressive/receptive deficits)
Nutrition/Swallowing
(eg Diet, swallowing issues)
Section 5: Barriers to discharge
Please comment on any known or potential barriers to discharge including home mods, VCAT proceedings, family conflict etc
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________

Please attach any further reports that may assist with the Transition Care Program referral process or
discharge plan; ie: Social work and/or Allied Health VCAT reports, VCAT Medical reports,
Neuropsychological reports etc.

If you are referring from within the networks of Western Health, Melbourne Health or Northern Health - email
all referrals to: WHS - Transition Care Referrals

If you are referring from outside of these three networks, the email address for Western Health Referrals
is: TransitionCareReferrals@wh.org.au