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: [email protected]
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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