Intake Referral Form

Welcome - this is where care begins.
Whether you're reaching out for yourself, someone you care about, or a patient, we are here to help. This form helps us understand what's needed so we can respond thoughtfully and support you in the right way.

We review every referral carefully and will be in touch to talk through the next steps.
We are here to help, but Wattle and River Home Health is not an emergency service. If there are any immediate safety concerns or someone may be at risk, please call 000.
Who is completing this form?
What is your name?

First NameLast Name
What is your contact number?
Please enter a valid phone number.Format: (000) 000-0000.
What is your relationship to the person?
Permission confirmation
Tell us all about you:
Please tell us your name:

First NameLast Name
Do you have a preferred name?
Date of birth

DayMonthYear
Date
Residential address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Best contact number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Preferred contact method
Best time to contact
Do you have an emergency contact?
Please include their name, relationship to you and the best contact number for them.
About you and your background:

So we can support you in the right way
Do you identify as Aboriginal and/or Torres Strait Islander?
Cultural background or country of origin
Preferred language
Interpreter required

Other
Are you a veteran or DVA cardholder?
Who lives with you?
Do you have family, friends or services currently supporting you?
If yes, which funding or support options apply?
If yes: Who, and how often?
If unsure, please tell us a little more about your current support system:
What is your regular doctor's name and where do they work?
Tell us a bit about your health and the support you may need:
What is the main reason you're seeking support?
What kind of support would you find helpful?

Other
If unsure, please tell us a little more about the kind of support you may need:
When do you need support?
If you're comfortable, please tell us about any health conditions you have:
Are you taking 5 or more regular medications?
If you're not sure, feel free to tell us anything you know about your medications:
Any allergies or adverse reactions?
Have you had a fall in the last 12 months?
If yes, please describe the falls you've had:
Have you been in hospital in the last 30 days?
If yes, could you please provide us with a short detail of your hospital stay?
How you're currently managing day to day:
Walking and moving around
Showering and dressing
Toileting
Meals and eating
Any concerns about memory, confusion or decision-making?
If unsure, please tell us a little more about memory, confusion or decision-making
What matters most to you right now?
Your usual routines, preferences or things we should respect
Your information and your privacy matter to us...
You can read more about how we manage your information in our Privacy Policy.
GP contact consent
Acknowledgement
About the person you're referring:
Name

First NameLast Name
Preferred name
Date of birth

DayMonthYear
Date
Gender
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Residential address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Does the person currently live at home?
If unsure, please provide more detail about their living situation
Who is the main contact for this referral?
If known, please provide the full name and contact details:
Let's talk about the support they might need;
What is the main reason for referral?
What kind of support may be helpful?

Other
If other, please provide more detail about the support they may need:
When is support needed?
Is this referral related to a recent hospital stay or discharge?
If yes, please provide details
Tell us a bit more about their health and how they're going day to day:
Current diagnoses or health conditions:
Relevant medical history:
Current medications (if known):
Mobility or transfer needs:
Personal care needs:
Cognitive or memory concerns:
Nutrition or hydration concerns:
Wellbeing, lifestyle or connection goals:
Help us understand their home environment, safety and supports:
Are there any risks we should be aware of?

Other
Is the home environment safe and suitable for care?
If unsure, please provide more detail about the home environment:
What are their usual routines or preferences?
What matters most to them in their care?
Are there cultural, language or family considerations?
Do you know their preferred days and/or times for support?
Is the person currently receiving support?
If yes, please provide more detail about current supports:
This includes NDIS, Home Care Packages, Friends and/or Family.
Who is their regular GP:
If known, please provide the clinic details.
Are there any other clinicians or services involved?
Has the person consented to this referral?
Consent and authority to share information
If consent cannot be obtained, please briefly explain
Upload any relevant documents

Cancelof
Is there anything else we should know?
Acknowledgement
Emergency notice
Should be Empty:

Whether you're reaching out for yourself, someone you care about, or a patient, we are here to help. This form helps us understand what's needed so we can respond thoughtfully and support you in the right way.

We review every referral carefully and will be in touch to talk through the next steps.

Tell us all about you:

About you and your background:

Tell us a bit about your health and the support you may need:

How you're currently managing day to day:

About the person you're referring:

Let's talk about the support they might need;

Tell us a bit more about their health and how they're going day to day:

Help us understand their home environment, safety and supports: