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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