Referral Referral Form Participant Details Preferred Dates From To Flexible with Dates Email Address Date of Birth Sex MaleFemale Does the participant smoke? YesNo Communication Interpreter requiredFollow instructionsNon-verbal gesturesComprehend dialogueCommunicate verballyUse some words Good understanding of English YesNo Who does the Participant usually reside with? Escort Is an Escort required? YesNo Travel Arrangements How is the participant travelling to Katherine FlightBush taxiAccompanied?Independent How is the participant travelling home? FlightBush TaxiAccompaniedIndependent Who will be responsible for Booking the transport? Medical Information Next of Kin Allergies YesNo Provide Details if YES Does the participant have and advanced Care directives? YesNo Other Information Does the participant make their own medical decisions? If NO, please provide contact details of the person responsible or Guardian. YesNo Current ACAT assessment? YesNo Has the participant had a fall in the past 6 months? YesNoOther information What is the primary care Need of Participant? Chronic diseaseDementiaMental HealthPalliativeChallengingDisabilityPhysical DisabilityYoung person with high care needsAutismHomelessness Does The Participant Have A Current Dhc Respite Care Plan? YesNo Relevant Medical History – attach additional information when needed What level of assistance does the participant require with activities of daily living? Showering and dressing IndependentStand by assistanceHands on assistanceFully dependent Toilet IndependentStand by assistanceHands on assistanceFully dependent Transferring IndependentStand by assistanceHands on assistanceFully dependent Mobility IndependentStand by assistanceHands on assistanceFully dependent Eating/Drinking IndependentStand by assistanceHands on assistanceFully dependent Moving Bed IndependentStand by assistanceHands on assistanceFully dependent Does the participant use any of the following Personal Aids? WheelchairShower chairGlassesWalking frameDenturesContact lensesWalking stickHearing aidsProsthesis Does the participant require any of the following? Please send to DHC with patient Regular Medications (blister pack preferred)Continence aids (pads, sanitary items)Nutritional supplements (e.g. Fortisip) PERSONAL PREFERENCES (Like, dislikes, Personality) CARER Does the participant have a carer? YESNo Does the participant reside with carer? YesNo
