Client Information and Referral Record I.D. Number Page 1 To be used in accordance with the Guidelines and Principles Client Information Title Full name Prefers to be called Usual Address Street Std Telephone. Suburb LGA State: SLA Postcode Current Address (if different) Std Telephone. Street Suburb LGA State: SLA Postcode Sex: Country of birth Ethnicity: of Birth Age Language spoken at home: Is language / Communicaton assistance required? Specify Cultural or Religious affiliations Indigenous Status Yellow Book has been left with client Aboriginal but not Torres Strait Is. Torres Strait Is. but not Aboriginal Both Aboriginal and Torres Strait Is. Neither Aboriginal or Torres Strait Is. Page 1a Source of referral Name Is the client aware of the referral? Contact. Is the carer aware of the referral? N/A What services are currently being received? Organisation (if applicable) Source of referral: Reason for referral and/or type(s) of assistance being sought What informal assistance is available on a regular basis (e.g. carer, friend, social club or church group)? Name of service receiving referral Referral received by Action Required Full Assessment Urgent ShortTerm
Client Contacts I.D../Name Page 2 Name of person providing the details Name of formal guardian (if applicable) Others present at assessment Telephone. (home) Telephone. (work) First contact/emergency contact person or carer Address Telephone. (home) Telephone. (work) Street: Suburb: Postcode: Address 2nd important contact Street: Suburb: Postcode: Telephone. (home) Telephone. (work) Is there a carer? Relation of Carer to Care Recipient: Carer Residency Status: 3rd important contact GP's Name Telephone. (home) Telephone. (work) Telephone. Client's usual living arrangements: Other Information Government benefit status: Page 2a Lives Alone Lives with Family Lives with Others t stated/inadequately described Accommodation Setting Other (specify) Private Health Insurance Company Number Aged Pension Veterens Affairs Pension Disability Support Pension Carer Payment Pension Unemployment related benefit Other government pension/benefit government pension or benefit t stated/inadequately described Other (specify) Government Benefit Number Pensioners Concession Card Number Unable to determine Ambulance Subscriber Type Does the client have a Department of Veterans' Affairs card? What does the client see as difficulties and/or health problems (eg hearing, allergies, incontinence)? Relevant Health Information How will any of these affect service delivery?
I.D../Name Page 3 Relevant Health Information (cont.) Tasks of Daily Living Please mark either an I, WA, D or NA I represents "Independent" WA represents "With assistance" D represents "Dependent" NA represents "t applicable" Shopping/Banking Preparing meals House work Minor home maintenance Use of telephone Transport Communication skills Community access Tasks of Self Care Is assistance required with the following: Bathe/Shower Dress/Undress Eat a meal Grooming Get in/out of bed Use the toilet Walking Footcare Comments Comments Equipment used to maintain independence Transport used Car Taxi Bicycle Public Transport Other/Comment Are there any factors about this home that could affect safety for/or access by: Client Carer Service Provider Home and Safety and Access Carer Page 3a Clients Service provider continued From the information gathered and in consultation with the client/carer, identify the client's needs Client Need and Referral Action Identify carer's needs
I.D../Name Page 4 Client Need and Referral Action (cont,) To which service(s) is referral needed GP/Hospital Home Modification / Home Nursing Maintenance Food services Community Access Allied Health Home Help/Home Care Transport COPS/Linkages ACAT Comm. Aged Care Packages Day Hospital Respite (Home/Residential) Personal Care Recreational Day Programs Linen services Social support services Other (e.g. advocacy or carer services) What complementary assessments could assist (e.g. DNCB, DVA, Transport subsidy) Agreed action of assessing service Agreed referral action Referring service notified of action taken te other information, literature, etc. provided I consent (Client) do not consent to this information being made available to the services nominated under Agreed Referral Action. Signature Client's Consent and Signature Comment if the client is unwilling or unable to sign (e.g. verbal agreement) Review By Whom Page 4a To be completed by person undertaking assessment Assessor Checklist Signature I (Name) acknowledge that I have: Informed the client/carer of the purpose of the assessment Informed the client/carer of their rights and responsibilities Contact. Organisation Outlined access to complaints mechanism and appeals process Identified the outcomes of the assessment and formally obtained endorsement of proposed actions, including referral(s) Position in the Organisation Advised that a copy will be left with them
I.D../Name Supplementary Supplementary referral information: Case Manager / Key Worker: Comments: Client Type: Aged Younger Disabled Other Dementia: Suspected Diagnosed Referral: Priority Comment