· Web viewAgency Referral Form Access to the Community Visitor Scheme is by referral from self,...
3
Whittlesea Community Visitor Scheme Agency Referral Form Access to the Community Visitor Scheme is by referral from self, family or an agency connected to the person. This form can be completed by a nurse, community, health/welfare, social services worker or a family member. REFERRAL DETAILS Date: ___/___/______ CLIENT DETAILS Family Name: ___________________ Given Name: __________________ Preferred Name: _______________ Gender: ________________________ Date of Birth: ___/___/____ Address:____________________________________________________________________ ______________ Phone Number: _____________________ Mobile: ___________________________ Is the client registered with My Aged Care? □Yes □No □Not Sure Is the client eligible for a Home Care Package? □Yes □No □Not Sure Country of Birth: ________________________ Cultural Background: ________________________ Preferred Language: ________________________ Interpreter Needed: Agency/Service Provider sending referral Name: ________________________ Position: ________________________ OR Family Member / Significant other making referral Name: __________________________ Relationship to client: ___________________________________ ____ Phone: __________________________ Email: __________________________
Transcript of · Web viewAgency Referral Form Access to the Community Visitor Scheme is by referral from self,...
Whittlesea Community Visitor SchemeAgency Referral Form
Access to the Community Visitor Scheme is by referral from self, family or an agency connected to the person. This form can be completed by a nurse, community, health/welfare, social services worker or a family member.
REFERRAL DETAILS
Date: ___/___/______
CLIENT DETAILS
Family Name: ___________________ Given Name: __________________ Preferred Name: _______________
Gender: ________________________ Date of Birth: ___/___/____
Address:__________________________________________________________________________________
Phone Number: _____________________ Mobile: ___________________________
Is the client registered with My Aged Care? □Yes □No □Not Sure
Is the client eligible for a Home Care Package?□Yes □No □Not Sure
Country of Birth: ________________________ Cultural Background: ________________________
Preferred Language: ________________________ Interpreter Needed: ________________________
Indigenous Status: ________________________
HEALTH STATUS Please include any issues that may impact on visits such as mobility, hearing, eyesight, continence, speech, dementia and/or challenging behaviour. This information will help ensure a suitable match.
Agency/Service Provider sending referral
Name: ________________________
Position: ________________________
Organisation: ________________________
Phone: ________________________
Email: ________________________
OR
Family Member / Significant other making referral
Name: __________________________
Relationship to client: _______________________________________
Phone: __________________________
Email: __________________________
Community Visitor Scheme-Whittlesea Community Connections 1 of 2
CLIENT BACKGROUND Can you tell us anything about the client that will help match a suitable volunteer, for example: living arrangements, family, cultural or religious needs, interests, current visitors and relationships or suggested activities for volunteer visitor?
PRIMARY CONTACT DETAILS /CARER DETAILS
Family Name: ___________________ Given Name: __________________ Preferred Name: _______________
Relationship to client: ______________________________
Address: _______________________________ Phone Number: _____________ Mobile: __________________
Country of Birth: ________________________________________ Language: __________________________
VISITOR PREFERENCES
Gender: ___________________
Age: ___________________
Language or Cultural Preferences: ___________________
Other things to consider: ___________________
Please return completed form by mail:
Community Visitors SchemeWhittlesea Community ConnectionsShop No 111,Pacific Epping, Epping 3076Phone: (03) 9401 6666
Email: [email protected]
Community Visitor Scheme-Whittlesea Community Connections 2 of 2
