Carefinder Client Referral Form

Client Relationships
Name

First NameLast Name
Nature of Relationship
If other, please describe:*
Does the client consent to a Care Finder contacting this person or support provider?*
Phone Number
Email
example@example.com

Final information
Does the client need an interpreter?*

YesNo
Interpreter required

Yes
Please state the language (including dialect, if applicable)*
Are there any preferred days of the week or times for contact?*
What is the client seeking?*

General information about aged careHelp navigating aged care
What are the main issues where the client would like help or information? *
Do you know if the client is currently receiving any Aged Care or Home Care services? If you are able to please provide details of Funding type:

CHSPHCP/Support at HomeOther
Information about services other than CHSP or HCP/Support at Home that are being provided, ie NDIS, Palliative Care etc
CHSP - Include provider name and details of any services being provided:
HCP/Support at Home - Include provider name and details of any services being provided:

CONSENT TO EXCHANGE INFORMATION
Who will be consenting on behalf of the client?*
Name of person consenting*

First NameLast Name
If client is not consenting, please state the relationship of person consenting to referral on client's behalf*
I, {name19} consent to COTA Tasmania and {referrersOrganisation} exchanging information about my/the client’s situation and service options. I am aware that my consent is valid for 12 months after this date, and I can withdraw my consent at any time, verbally or in writing.*

Yes, I consent
consented?

Yes
Personal Information Collection Statement

At all times we try to only collect the information we need for the particular function or activity we are carrying out. The main way we collect personal information about you is when you give it to us, for example, personal information such as contact details and support needs. Sometimes we need to collect sensitive information to help us connect you to the right supports. This might include information about your health, needs, circumstances or culture. We only disclose your sensitive information for the purposes for which you gave it to us. We will ask for your consent before we do so.
Status*
Should be Empty:

Carefinder - Client Referral Form