Referral Form Referral Location(Required) The Queenslea Retirement Apartments The Queenslea Aged Care The Richardson Aged Care Name TitleDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Address Street Address City Post Code Email Telephone Date of Birth DD slash MM slash YYYY GenderMaleFemaleOtherDo you live alone? Yes No Specify Are you a Home Owner Private Residence Public Rental Other Other Primary ContactPrimary Contact Client Other Other Contact Name First Name Last Name EPOA Yes No Relationship to Resident Telephone Referral InfoIncome TypePart PensionFull PensionSelf FundedDVA (card colour) Gold White Orange DVA Card Number Country of Birth Aboriginal/TSI Yes No Communication Verbal English Verbal Non-English Non Verbal Non-Verbal (Specify) Type of residency Respite Permanent Both Reason for referralRelevant past medical historySupport ServicesDoes the resident have any support services in place? Yes No Current Support Services CHSP Home Care Package Level 1 Home Care Package Level 2 Home Care Package Level 3 Home Care Package Level 4 DVA Other (e.g. NDIS) Please identify type of support, service providers and level of informal support received by residentHospital Admission / After CareHospital Admission date DD slash MM slash YYYY Discharge date DD slash MM slash YYYY GP / Specialist Telephone Geriatrician Telephone Please indicate the resident’s level of function: Low (Level 1) Minimal / Stand by Moderate (Level 2) Assistance of 1 High (Level 3)* Assistance of 2 Bathing Low Moderate High Dressing Low Moderate High Eating Low Moderate High Mobility Low Moderate High Toileting / Incontinence Low Moderate High SPC Yes No IDC Yes No Meals Independent Assist / Prompt Full Assistance Toileting / Incontinence Low Moderate High Medication Low Moderate High Is the resident taking psychotropic medication?(Required) Yes No If yes, please list the medications and the reason for each prescription:Does the resident require assistance with transport? Yes No Has an OT Assessment been done in this current hospital admission?(Required) Yes No OT AssessmentMax. file size: 10 MB.(Please attach a copy of the OT Assessment)Has a cognitive assessment screening tool been completed?(Required) Yes No Please list the assessment and score obtained Additional Aid AssistanceAre there any assistive aids in place? (i.e. shower chair, walking frame) Shower Chair 4 X Wheeled Walker Sara Stedy Toilet Riser Wheelchair Stand Up Lifter Commode Electric Wheelchair Hoist/Sling Lifter Walking Frame Electric/Hospital Bed Other If other, please specifyIs the resident a high fall risk? Yes No Does the resident have dementia? Yes No Does the resident have Parkinson’s? Yes No Does the resident have wandering behaviours? Yes No Are there any cognitive behavioral issues that may impact on other residents /staff? Yes No If Yes, please provide details:Please state additional information that could assist us to provide appropriate support/s for this resident, such as any special requirements due to cultural background, religion, male/female support worker etc.Referrer DetailsAgency or Health provider(Required) Name Phone Number Email ConsentThis consent authorises ORYX to use information in this referral for the purpose of planning, organising and delivering services, as requested.Written Consent From Resident Guardian Resident/Guardian Name Verbal Consent From Resident Guardian Resident/Guardian Name
