Home Health Rehab- Aged Care Referral Form

PATIENT DETAILS
First Name:*
Last Name:*
Date of Birth*

DayMonthYear
Date of Birth*

DayMonthYear
Date
Gender:
Pronouns:
Phone No:*
Address:*
City/Suburb:*
Postal Code:
Patient or NOK/emergency contact email address: *
(if none available type N/A)
Emergency Contact Name
Emergency Contact Phone No.
Falls History
Significant Medical History:
Lives:
Type of Building:
Name, Address and Ph of Patients GP:
Supporting Documentation (discharge notes / GP letters etc)

Cancelof
CARE COORDINATOR / REFERRER DETAILS
Care Coordinator / Referrer Name:*
Care Coordinator/ Referrer Email:*
Care Coordinator/ Referrer Ph:
PHYSIOTHERAPY REFERRAL

Please note ALL initial physiotherapy assessments include a comprehensive physiotherapy report sent to the care coordinator / referrer with recommendations.
Reason for Physiotherapy Referral

Falls Prevention ProgramGait aid assessment / Recommendation (4WW or SPS)1:1 HydrotherapyMusculoskeletal aches and painsPrehab for surgeryRehab post surgeryDeconditioning following illness / hospital admissionDiabetes ManagementLightweight Wheelchair AssessmentRespiratory PhysioSmall aids and equipment (over toilet aid, shower stool)
Please note ALL Initial appointments will come with a comprehensive physio report
Follow Up Aged Care Falls Risk Assessment Report
Physiotherapy Equipment Recommendations / Obtaining Quotes
Physio visits approved e.g. 1x week, 1 x fortnight, 6 week exercise block, weekly hydrotherapy, discuss with physio after 1st consultation
How frequently do you require review reports? (e.g. end of recommended treatment block, every month, when requested)
STRC end date (if applicable)

DayMonthYear
Date
Further Information: e.g. best contact for appointment, NESB
OCCUPATIONAL THERAPY REFERRAL

Please fill in this section for occupational therapy referral- Please select if you would like a comprehensive assessment where all items of concerns are flagged with recommendations OR a focussed assessment.
Comprehansive Occupational Therapy Assessment

Prescription of equipment for ADLsWheelchair assessmentElectric Lift Recliner AssessmentMotorised Mobility Device Assessment (scooter / powered wheelchair)Bathroom / toilet assessmentRamp / stair modificationGrab rail assessmentElectric bed / hospital bed assessmentOther
Type of OT Assessment Required:

Comprehensive OT Assessment (All areas are assessed and the OT will make recommendations regarding areas of concern- 3hrs inclusive of report. Further approval required from care coordinator before proceeding with equipment trials / home mod quotes)Focused OT Assessment (see below)
FOCUSED Occupational Therapy referral (Select which area/s will be the focus of the assessment and completed as priority)

Prescription of equipment for ADLsNon-powered wheelchair assessmentElectric lift recliner assessmentMotorised mobility device assessment (scooter / powered wheelchair)Bathroom / toilet assessmentRamp / stair modificationMinor home mods (grab rails)Electric bed / hospital bed assessmentOther seating prescriptionOther
High Risk / Urgent referral checklist:

Current pressure care injuryPast history of pressure care injuryFall within the last monthRecurring falls
OT reporting
STRC end date (if applicable)

DayMonthYear
Date
OT hours approved ($200 p/h ex gst)
Further Information: e.g.additional items to be assessed, best contact for appointment, NESB, how many quotes required
INVOICING
Aged Care Provider/ Billing to:*
Email invoice to:*
Should be Empty:

PATIENT DETAILS

CARE COORDINATOR / REFERRER DETAILS

PHYSIOTHERAPY REFERRAL

OCCUPATIONAL THERAPY REFERRAL

INVOICING