(Affix patient identification label here)
URN:
Family Name:
Metro North Hospital & Health Service
Subacute and Ambulatory Service
Given Names:
Community Based
Rehabilitation Team Referral
Address:
Date of Birth:
Sex:
M
F
ATTACH A DISCHARGE /MEDICAL SUMMARY TO THIS REFERRAL
Client Consent
Yes
No
Reason if No
Date of Referral
Is the Client Motivated
Yes
No
Reason if No
Diagnosed Related to Referral
Date
Stoke
Brain Dysfunction/Trauma
Neurological Conditions
DO NOT WRITE IN THIS BINDING MARGIN
Orthopaedic Conditions
Spinal Cord Dysfunctions/Trauma
Amputation (note where)
Other Disenabling Impairment
Aids Used
Hygiene
Yes
No
Dressing
Yes
No
Grooming
Yes
No
Mobility
Yes
No
Stairs
Yes
No
Upper Limbs
Yes
No
Lower Limbs
Yes
No
Bladder
Yes
No
Bowel
Yes
No
Toileting
Yes
No
Feeding
Yes
No
Swallowing
Yes
No
Communication
Yes
No
Memory
Yes
No
Driving
Yes
No
Access to Transport
Yes
No
Additional Information
Has the client had recent rehabilitation?
Yes
No
Version 1.0 August 2013
Location (drop down box Inpatient, outpatient)
Where
Has the client been given a HEP
Yes
No
Does the client live alone
Yes
No
Cognitive Score
Dates
to
/30 (drop down box MMSE, RUDAS)
Referral to (Tick all that apply)
Occupational
Therapist
Physiotherapist
Leisure Therapy
Social Worker
Medical Issues
Social Issues
Other Services Involved (State who is involved and how often the service is provided)
Page 1 of 2
Speech Pathologist
COMMUNITY BASED REHABILITATION TEAM
Current Functional Status (help needed with) 0-None 1-Minimal 2-Moderate 3-Substantial
(drop down box under status 0-None 1-Minimal 2-Moderate 3-Substantial)
Function
Status
Aids Used
Function
Status
(Affix patient identification label here)
URN:
Family Name:
Metro North Hospital & Health Service
Subacute and Ambulatory Service
Given Names:
Community Based
Rehabilitation Team Referral
Address:
Date of Birth:
Sex:
M
F
Other Services Involved (State who is involved and how often the service is provided)
Multi-Disciplinary Goals and Issues
Referrer Details
Name
Address/Agency/Practice
Telephone
Fax
Email Address
Hospital Details (if applicable)
Hospital & Ward
Consultant Name
Admission Date
Sex
M
F
Date of Birth
Address
Telephone
Mobile
Indigenous Status (drop down box Aboriginal/Torres Strait Islander/Both Aboriginal and Torres Strait Islander/NonIndigenous)
Does the client require an interpreter?
Medicare No
Yes
No
Unknown If yes, language spoken
Expiry Date
Government Benefit
Card No
(drop down box No Benefit/Aged Pension/Carers Pension/Disability Pension/Unemployment Benefit/Veteran
White/Veteran Gold)
Health Insurance
Card No
Company
(drop down box None/Hospital Only/Extras Only/Hospital & Extras/3rd Party/Workers Compensation Motor Vehicle)
Emergency Contact
Name
Address
Telephone
Mobile
Relationship to Client
Does the client have an EPOA?
EPOA Name
Yes
No
Unknown
Telephone
REFERRAL SUBMISSION
Brisbane City Council area
Fax: 3139 6522
Enquiries: 1300 658 252
Moreton Bay Regional Council area
Fax: 3049 1260
Enquiries: 1300 658 252
Page 2 of 2
DO NOT WRITE IN THIS BINDING MARGIN
Client Details
Title
Name
Discharge Date