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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 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 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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