ComPacks referral form

ComPacks referral form

Date

MRN

Hospital

Surname

First name

Preferred name

Sex

• Male
• Female

Date of birth

Address

Medicare no

Phone

Mobile

Marital status

• Divorced
• Married
• Never Married
• Separated
• Widow/widower
• N/A

Living arrangement

• Lives alone
• lives with family
• lives with others
• N/A

Abode type

• Independent living unit
• Private purchased
• Private rental
• Supported accom
• other

Does the client have a carer?

• Yes
• No

Carer Name

Carer Contact Number

Carer Residency

• non-resident
• co-resident
• N/A

This Referral came from

• Hospital in the Home/APAC
• Healthy at Home
• Hospital/Ward

Estimated Date of Discharge

Does the Client Consent to this Referral

Client Emergency/Alternate Contact

Name

Phone

Relationship to client

GP Details

Name

Phone

Suburb

DVA Gold Card Holder

Workers Comp Claim

MVA Insurance Claim

Other

Upon discharge home, will the client be able to manage independently for the next 48 hours?

• Yes
• No

Indigenous Status

• Aboriginal and/or Torres Strait Islander
• Neither Aboriginal and/or Torres Strait Islander
• Declined to respond
• Unknown

Country of Birth

Main language spoken at home

Is an interpreter required

• Yes
• No

Date/Time of Booking

Reason for admission/Relevant Health Issues

Services received prior to current hospital admission/or current service provider

• Transition Care
• Respite Services
• Medication Supervision
• Palliative Care
• Personal Care
• Domestic Services
• Meals on Wheels
• Disability Services
• Mental Health Services
• CAPACS (HITH)
• DVA Gold Card
• Home Care Package
• Transport
• Community Nursing
• Other

Other referrals made (e.g. My Aged Care, ACAT, Home modifications)

Other relevant psycho-social issues

Services requested (case management included, services will be negotiated within the constraints of the package)

• Social Support
• Personal Care
• Meal Prep/or Meals on Wheels
• Transport
• Shopping
• Domestic Assistance
• Respite Care
• Medication Supervision
• Other

Known WHS Issues/Risk assessment (i.e. pets, substance abuse, violence history etc.)

Allied Health/Equipment

Does the client require any equipment?

• Yes
• No

Has the Equipment been provided?

• Yes
• No

Has the client been cleared for discharge by OT/Physiotherapist?

• Yes
• No

Additional Information:

Referrer Name

Alternate staff contact

Contact Phone Number

Alternate staff Phone Number

Email

Referrer Facility

Date & Time

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