OFFICE USE ONLYReceived: ___ / ___ / ____

Service ProviderReferral Form

1. Key contact person Referral is: Priority Routine

Risk issues: Yes No

Relationship to person with dementia/memory loss:      

Surname:       Given name:      

Date of birth:       ☐ Est Age

:       Gender: ☐ M ☐ F

Address:      

Suburb:       Postcode:       State:      

Phone (H):       Phone (W):      Mobile:       Email:      Country of birth:      Restrictions on contact/best times:      

Language spoken at home:       Preferred language:       ☐ Interpreter required

Indigenous: ☐ No ☐ Aboriginal ☐ Torres Strait Islander ☐ Aboriginal and TSI ☐ Unknown

Special needs: ☐ GLBTI ☐ Homeless or risk of homelessness ☐ Younger onset dementia

Income Type☐ Aged Pension ☐ Other government pension or benefit ☐ Unemployment-related benefits☐ Carer Payment ☐ Service Pension ☐ Veterans’ Affairs Pension (Gold)

☐ Disability Support Pension ☐ Sickness Allowance ☐ Veterans’ Affairs Pension (Other DVA Card)

☐ No Pension ☐ Sole Parent Pension ☐ Veterans’ Affairs Pension (White)☐ Not stated/inadequately described ☐ Special Benefit ☐ Widow’s Pension

☐ Not a DVA Card holder

DVA Card Status☐ Not stated/inadequately described ☐ DVA Card None ☐ DVA Card White☐ DVA Card Gold ☐ DVA Card Orange ☐ DVA Card Other

Accommodation☐ Boarding house/private hotel ☐ Private residence – public rental ☐ Share supported accommodation

☐ Community housing ☐ Private residence – private rental ☐ Short-term crisis, emergency or transitional accommodation facility

☐ Domestic-scale supported living facility ☐ Private residence rented from Aboriginal comm. ☐ Supported accommodation facility☐ Group home ☐ Private residence – mobile home ☐ Supported residential care

☐ Independent living within retirement village ☐ Psychiatric/mental health community care facility ☐ Temporary residence in Aboriginal comm.

☐ Not stated/inadequately described ☐ Residential aged care: high level care ☐ Other☐ Private residence – owned/purchasing ☐ Residential aged care: low level care

Living Arrangements☐ Lives alone ☐ Lives in residential high care facility ☐ Other☐ Lives with family ☐ Lives in residential low care facility ☐ Homeless☐ Lives with spouse ☐ Lives in transitional care ☐ Not stated/inadequately described

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2. Person with memory loss/dementia (if not key contact person)

Surname:      Given name:

     

Date of birth:

      ☐ Est Age:

      Gender ☐ M ☐ F

Address:      

Suburb:       Postcode:      State

:     

Phone (H):       Phone (W):

     

Mobile:       Email:      

Country of birth:      Language spoken at home:       Preferred

language:       ☐ Interpreter required

Indigenous: ☐ No ☐ Aboriginal ☐ Torres Strait Islander ☐ Aboriginal and TSI ☐ Unknown

Special needs: ☐ GLBTI ☐ Homeless or risk of homelessness ☐ Younger onset dementia

Dementia/memory loss details

Dementia type:       Date of diagnosis:      

Diagnosed by:       Role:       Is dementia confirmed:      

Income Type☐ Aged Pension ☐ Other government pension or benefit ☐ Unemployment-related benefits☐ Carer Payment ☐ Service Pension ☐ Veterans’ Affairs Pension (Gold)

☐ Disability Support Pension ☐ Sickness Allowance ☐ Veterans’ Affairs Pension (Other DVA Card)

☐ No pension ☐ Sole Parent Pension ☐ Veterans’ Affairs Pension (White)☐ Not stated/inadequately described ☐ Special Benefit ☐ Widow’s Pension

☐ Not a DVA Card holder

DVA Card Status☐ Not stated/inadequately described ☐ DVA Card None ☐ DVA Card White☐ DVA Card Gold ☐ DVA Card Orange ☐ DVA Card Other

Accommodation☐ Boarding house/private hotel ☐ Private residence – public rental ☐ Share supported accommodation

☐ Community housing ☐ Private residence – private rental ☐ Short-term crisis, emergency or transitional accommodation facility

☐ Domestic-scale supported living facility ☐ Private residence rented from Aboriginal comm. ☐ Supported accommodation facility☐ Group home ☐ Private residence – mobile home ☐ Supported residential care

☐ Independent living within retirement village ☐ Psychiatric/mental health community care facility ☐ Temporary residence in Aboriginal comm.

☐ Not stated/inadequately described ☐ Residential aged care: high level care ☐ Other☐ Private residence – owned/purchasing ☐ Residential aged care: low level care

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Living Arrangements☐ Lives alone ☐ Lives in residential high care facility ☐ Other☐ Lives with family ☐ Lives in residential low care facility ☐ Homeless☐ Lives with spouse ☐ Lives in transitional care ☐ Not stated/inadequately described

Other key agencies/services involvedContact person/agency Address Phone                                                   

Reason for referral (if risk has been identified, please detail nature of the risk and how it has been managed to date)

     

Needs and/or issues requiring assistance☐ Behavioural concerns ☐ Dealing with diagnosis ☐ Memory Lane Café ☐ Support and care☐ Carer stress ☐ Education ☐ Planning for the future ☐ Younger onset dementia☐ Coping and mental health ☐ Family and relationships ☐ Progression of the disease ☐ Other:      ☐ Counselling ☐ General information ☐ Social isolation

Referred byName of worker:       Rol

e:      

Organisation:      

Postal address:       Suburb:       Postcod

e:      

Phone:       Email:      

I would like a brief letter/email advising me whether the key contact person has accepted AAV services: ☐ Yes ☐ No

Consent

☐ I have discussed this referral with the key contact person, and they consent to being contacted by Alzheimer’s Australia Vic.

Name:

     Signature:

     Date:

     

Return to: Gateway Services Alzheimer’s Australia Vic Locked Bag 3001 Hawthorn Vic 3122 Fax: (03) 9815 7801 Email: aav.gatewayteam@alzheimers.org.au

To discuss this referral please contactGateway Services on (03) 9815 7800

Connecting Care members can choose to send referrals via a secure connection at http://www.connectingcare.com

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