ABI Specialist Services - Victoria. arbias Neuropsychological Assessment & Intervention Services Referral form. Date of Referral:

Transcription

1 ABI Specialist Services - Victoria Neuropsychological Assessment & Intervention Services (NPAIS) Referral Form If the referral relates to a legal matter (excluding guardianship and administration), please refer to the Private Clinic Referral Form. Date of Referral: Referral urgency: HIGH ROUTINE Please note: HIGH urgency referrals must include a cover letter addressed to the NPAIS Manager outlining the urgency of the nature and urgency of the referral. Name (include alias if applicable) Client Details Post code Date of birth Gender Age Phone Country of birth Interpreter required? Preferred language? Is the person Aboriginal or Torres Straight Islander? Describe the clients current living situation (type of accommodation, duration of residence, alone, with partner etc) Is there any support provided at current accommodation? Can the person read and write? Does the client have any social supports? (Friends, family members, case worker etc) Referrer Details Comments Name and organisation Phone/Mobile Fax Page 1 of 7

2 Referrer Details Please outline your current role with the client: Referral Question Section Please answer ALL questions in this section Why are you referring the client for a neuropsychological assessment? What are the difficulties that the client is currently experiencing that you think may be related to possible brain impairment? Memory Attention/Concentration Problems Behavioural Concerns/Personality Changes Problem Solving Visual or Spatial Problems What areas of concern would you like addressed in the assessment report? Decision making capacity Details of current decision issues: Target Group Assessment (please specify) Recommendations/strategies for Case Management Access to services (housing, support agencies etc) Is the report going to be used for a particular purpose? VCAT Access to support services Case Management support (e.g. Participation in community programs etc) Community Corrections Order (CCO) Are there any risks to the neuropsychologist? (Physical aggression, triggers) Page 2 of 7

3 ABI (Acquired Brain Injury) Risk Factors Stroke Hypoxic (reduction of oxygen) Brain Infection Traumatic (MVA/falls) Professional Fights Epilepsy Brain Tumor Brain Surgery Assaults Suicide Attempts/Blood Loss Details of ABI (date of injury, hospitals attended and treatment) Alcohol and Other Drug (AOD) History (complete only if applicable) Please provide details in the table below: E.g. Alcohol, cannabis, amphetamines (e.g. speed, ice,), opiates (e.g. heroin, morphine), cocaine, ecstasy, GHB, hallucinogens (e.g. LSD), benzodiazepines (e.g. Valium, Xanax),inhalant s (e.g. paint, glue, petrol), or any other substance. Substance of choice: Substance Age first used Age of first regular use When last taken Total length of heavy use (months/years) Overdoses or loss of consciousness? How often? How long? Has the client had any of the following? Neuropsychological/Cognitive Assessments Brian Imaging (CT or MRI) Psychological/Psychiatric Assessment or admissions Alcohol or Substance detoxification/rehabilitation Please provide details and attach any relevant reports/ documentation: Page 3 of 7

4 General Information Please state the client s current source of income: Is there a Legal Guardian or Administrator? Please provide details: Employment/Education Highest educational achievement (year level): Current occupation and duration: Previous employment history: Legal status None Bond Parole CCO/CBO Please attach a copy Child custody/ family dispute Please list any current or past medical illnesses: Current medications Please list any current or past psychiatric/mental illnesses: Current medications: Is the client involved with a DHS service? Is there a history of violent offences or sexual offences? Page 4 of 7

5 MUST BE COMPLEETD DHS requirements Support Needs How often does the client need personal HELP or SUPERVISION with ACTIVITIES or PARTICIPATION in the following life areas? Life Areas Unable to do OR always need help in the area Sometimes needs help OR supervision in the area Does not need help in this area but uses aides Does not need help in this area and does not use aides Self care Mobility Communication Interpersonal interactions & relationships Learning, applying knowledge and general tasks and demands Education Community (civic) & economic life Domestic life Working Participation To what extent does the person participate in the following life areas? Life Areas Fully Partially Not at all Not known Getting around outside Using Transport Maintaining family relationships Maintaining social relationships Recreation or leisure activities Working Handling money Page 5 of 7

6 Other Services Involved Please list any other relevant services involved that may require a copy of the assessment report (pending client s consent) Name and organisation Phone/Mobile Fax Name and organisation Phone/Mobile Fax *Please attach details of additional services if there is insufficient space on this form. Please complete before submitted referral form Referrer Checklist Have all questions in the Referral Question Section answered? Have you attached any supporting documents to the application? Have all questions in the DHS requirements section been answered? Have you sent the medical information page to the client s GP? Yes No Yes No Yes No Referrer Declaration Please complete before submitted referral form I confirm that I have discussed this referral to arbias neuropsychological services with the client, (Insert client s name)... and they have consented to this. Referrer s name:... Signature:... Date:... Page 6 of 7

7 ABI Specialist Services - Victoria Medical Information Referrer - Please fill in client s name & date of birth details and then fax or this form to the clients GP for completion Dear Dr, We refer to the following client: Client name:... Date of Birth:... This client has been referred to arbias for a neuropsychological assessment. Please complete the section below (or attach a Patient medical Summary) & send to: arbias Attn: NPAIS Manger PO Box 5002 BRUNSWICK VIC 3056 Fax: (03) This information will provide important background information in anticipation of their neuropsychological assessment. GP Name & Medical History Current medications Is there a history of brain impairment or injury? (Duration of coma/pta, hospitals attended) Please specify Previous investigations (CT, MRI Scans) Please specify Please specify any other relevant details GP Signature Date Page 7 of 7