Tasmanian Community Care Referral Service	
   Referral Form	

Monday-Friday 8:00am – 6:00pm
(Excluding public holidays)		Telephone referrals:	1300 769 699
	Fax referrals:	1300 721 611	
Please note: referrals are required to be received by midday where action is required the next business day.	

CLIENT DETAILS:
Title: <<Patient Demographics:Title>>  First name: <<Patient Demographics:First Name>>	Surname: <<Patient Demographics:Surname>>	

Date of birth: <<Patient Demographics:DOB>>	

Address:  <<Patient Demographics:Full Address>>	Accommodation: 		own home		private rental	
Lives alone:		yes		no			public rental	
Telephone: (h) <<Patient Demographics:Phone (Home)>> (m) <<Patient Demographics:Phone (Mobile)>>	Country of birth: <<Patient Demographics:Country of Birth>>	
Client consent obtained: 		 	Interpreter required: 		yes  		no	
Language spoken at home: <<Patient Demographics:Language Spoken>>	Pension type: (specify)	
Indigenous status: 		Aboriginal 		Torres Strait Islander		Aboriginal and Torres Strait Islander	
               		Not Aboriginal	

CARER DETAILS:
Name: <<Carer's name>>	Relationship to client: <<Relationship to client>> 	
Address: <<Carer's address>>	Phone:  <<Carer's contact no.>>  	
Next of kin details: (if different from carer)   <<NOK name (if diferent to carer)>>  <<NOK relation>>  <<NOK contact>> 	

 REQUEST FOR SERVICES:	 Short term: (less than 12 weeks)  		 Long term/ongoing: 		

	Allied health (*specify details below)		Domestic assistance (housework)		Respite in home	
	Case management (*specify details below)		Delivered meals		Shopping	
	Centre based day care		Home maintenance (*specify details below)		Social support (*specify details below)	
	Counselling/information/advocacy		Home modifications (*specify details below)		Transport	
			Personal care (*specify details below; include aids)		Other: (*specify details below)	
*Specify details: (example: Allied health - physiotherapy required to assist client after stroke)

								
		 Complete if community nursing is required: (including clinic)						
		 Date of 1st visit:    __________						
		 Medication assistance (can not commence unless drug chart provided)	Drug chart faxed:		 Yes		 No	
		 Wound care (can not commence unless drug chart provided)	Wound chart faxed:		 Yes		 No	
		 Other: (specify)						
								
		 Discharge address: (if different to above) 						

CURRENT REFERRAL DETAILS:
Current diagnosis/treatment: 
	
Relevant medical and social history: (Including current service provider details) 
	
Past history:
<<Clinical Details:History List>>	
Social history:
<<Clinical Details:Social History>>	
Alerts: cognitive/falls/home environment: (please specify)
	
Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>	

REFERRER AND GP DETAILS:
Referrer name:  <<Doctor:Name>>	Position:  	
Organisation:  <<Practice:Name>>	Phone: <<Practice:Phone>>	
		
GP name:  <<Doctor:Name>>	Phone:  <<Practice:Phone>>	
Address: <<Doctor:Address>>	Date:   <<Miscellaneous:Date>>	
Thank you for your referral
IMPORTANT NOTICE - The information in this document is confidential. If you receive this message in error, please notify us immediately and return the original message to the sender.