Making Connections Referral Form
Referrals are accepted for people over 65 in Dublin South/ South East (HSE Community Healthcare East CHN’s 1- 6). Please note: you will receive a copy of the completed form by email after submission
SERVICE SELECTION
What service would you like to make a referral for?
*
Individual Supports
Making Connections Walk & Talk Programme
Making Connections Walk & Talk Programme Options
Location
*
Churchtown
Leopardstown
Individual Support Options
Please tick any that apply.
Social & Practical
Befriending
Phone Support
Support to engage in local activities
De-Cluttering
Support to fill forms/ use digital devices
Hospital discharge support
Other (please specify)
Signposting/ Linking
Housing Adaptation (dlr Healthy Homes)
Living Well Programme
Personal Alarm
Care & Repair
Sage Advocacy (Fair Deal)
Assistance to use Dublin Bus
Accessible library options (delivery/ audio)
Helplines
Other (please specify)
Main reason why support is needed:
*
CLIENT PROFILE
LIVING SITUATION - tick all that apply:
*
Lives alone
Lives with Spouse/ Partner
Lives with Family
Other
PRACTICAL SUPPORTS - tick all that apply:
*
Rows
Yes
No
Home Support
Day Centre
Visits from Family
Visits from Friends/ Neighbours
If any of these supports are in place - give details (days/ times)
*
COMMUNICATION CHALLENGES: Do any of the following apply?
*
Rows
Yes
No
Visual Impairement
Hearing Impairment
Speech Impairment
Cognitive Impairement
If yes, please give details
INFORMATION RELEVANT TO HOME VISITS
*
Client is a smoker
Client has a pet
N.A.
Other
Client's previous occupation
Client's interests/ hobbies
Any RISK concerns?
*
MOBILITY STATUS
*
Rows
Yes
No
Client can mobilise independently +/- walking aid
Client does NOT require physical assistance to mobilise
Client can mobilise outdoors > 15mins
Mobility Aid Used
*
Nil
Walking Stick
Crutches
3 Wheel Rollator
4 Wheel Rollator
COGNITION STATUS:
*
Rows
Yes*
No
Does the client have cognitive impairement?
*If 'Yes' Please provide formal cognitive test score if known (e.g. MOCA/ MMSE)?
*If 'Yes' Please provide details of nominated person to accompany them on the walk
First Name
Last Name
*If 'Yes' Nominated Person - Relationship to client:
*If 'Yes' Nominated Person - Phone:
*If 'Yes' Nominated Person - Email
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Next
Client Personal Details
1.1 Client Name
*
First Name
Last Name
1.2 Client D.O.B.
*
-
Day
-
Month
Year
Date
1.3 Client Phone number(s)
*
1.4 Client Email Address (where relevant)
example@example.com
1.5 Client Address
*
Address line 1
Address line 2
Area
County
Eircode
1.6 GP Name + Practice
*
1.7 Client's PHN (if known)
Emergency Contact Person
This can be NOK or other suitable person. In case of emergency, we need to be able to contact someone outside of office hours.
2.1 Name
*
First Name
Last Name
2.2 Relationship to Client
*
2.3 Location (County/ Country)
*
2.4 Personal Mobile Number
*
2.5 Email Address
example@example.com
Consent for Referral
Who has provided consent for this referral?
*
Client
NOK/ Alternative Contact
I confirm that I have discussed the referral with the client/ nok and confirm that the Client has given informed consent to be referred to Making Connections and understands that information may be shared with relevant HSE Staff as required.
*
Yes
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Next
Final Section - Referral Agent Details
3.1 Name
*
First Name
Last Name
3.2 Occupation
*
Please Select
PHN
Occupational Therapist
Physiotherapist
Social Worker
Other
3.2 Clinician Type
PHN
CRGN
Physiotherapy
Occupational Therapy
Social Work
Psychiatry/ Mental Health
GP
Other (please specify)
3.3 Primary Care Team/ Location
*
3.4 Phone Number(s)
*
3.5 Your Email
*
A copy of the completed referral form will be sent. For privacy reasons, do not use a shared mailbox email.
Any additional comments/ information (optional)
*
I consent to my data being stored in accordanceto the Making Connections GDPR Policy.
Submit
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