Aged Care Referral Form

Client Details

First Name of Client *

Surname of Client *

Client Gender *

Male: he - himFemale: she - herNon-binary: they - themPrefer not to sayOther

Client Date Of Birth *

Client Address *

Street addressStreet address line 2

City

State

Postcode

Country

Client Contact Phone Number *

Client Email Address *

Do You/ Does the participant Identify as Aboriginal or Torres Strait Islander? *

NoYes - AboriginalYes – Torres Strait IslanderYes - Aboriginal and Torres Strait Islander

Client Living Arrangements *

AloneFamily/PartnerSupported AccomodationOther

Is an Interpreter required? *

YesNo

Please indicate the Translator/interpreter or the communication aids required

Additional contacts

Alternative Contact Name

Alternate Contact Number

Relationship to the participant

Family member / Next of KinHome Care ProviderCase Manager ManagerAdministrator

PRIMARY DISABILITY / HEALTH BACKGROUND

Medical History *

Diagnosis *

Services

Primary Allied Health services required *

Exercise PhysiologyDietitian

Desired Outcomes / Goals

Please enter goals/outcomes *

Preferred Delivery of Services *

In Clinic at closest Avanti Health CentreAt home via telehealth

Wishing to receive Exercise Physiology supports at which Avanti Health Centre site? *

CaloundraSouthportTownsvilleHobsons BayMackay

Safety Considerations

Participant Risks *

Risk of injury or harm to their person or othersHomelessnessSubstance abuseCriminal historySexualDo not knowNone

Participant Behaviours *

Physical aggressionVerbal outburstProperty damageSelf injurious behaviourDo not knowNone

Other behaviours and risks that we need to be made aware of? *

Referrer Information

Name of Referrer *

Name of Organisation *

Referrer's Role *

Home Care ProviderFamily MemberOther

Contact number *

Referrer email address *

Please upload relevant files and associated documents here *

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Payment

Please provide the name of the person responsible for the account.

Name *

Surname

Email *

Contact Phone Number *

One of Avanti Health Centre's team will be in touch with you within two business days to discuss your referral.

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