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Collects patient demographics, referral dates and expected discharge date, Medicare number, Aboriginal/Torres Strait Islander status, interpreter needs, contact details, and general practitioner information. Captures relevant health history and clinical considerations including current functional status, orthopaedic restrictions, falls and pressure injury risk, communication, nutrition, cognitive and social issues, plus mental health and drug or alcohol history. 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O   ADDRESS    \nLOCATION/WARD   COMPLETE ALL DETAILS OR AFFIX CLIENT LABEL HERE  \n\n| Service Referring to:\u003Cbr>฀ Public Outpatients Fax: (02) 8088 3895 Phone: (02) 9808 9218\u003Cbr>[outpatients@royalrehab.com.au](outpatients@royalrehab.com.au)\u003Cbr> Home Based Rehab* Fax: (02) 8415 7122 Phone: (02) 9808 9687  [cbrs@royalrehab.com.au](cbrs@royalrehab.com.au)[ ](cbrs@royalrehab.com.au)*This is a multidisciplinary service. Single referrals are not accepted for Home Based Rehab\u003Cbr>|  |  |  |\n| --- | --- | --- | --- |\n| Please Tick services requested:\u003Cbr>☐ Dietitian\u003Cbr>☐ Social Work\u003Cbr>☐ Nursing\u003Cbr>☐ Neuropsychology (Limited availability) |  | ☐ Occupational Therapy\u003Cbr>☐ Physiotherapy\u003Cbr>☐ Speech Pathology\u003Cbr>☐ Aquatic Physiotherapy (Outpatients Only) |  |\n| Client aware of referral? ☐ Yes ☐ No |  |  |  |\n| Date Referred: |  | Expected Discharge Date: |  |\n| Clients Name: |  | Medicare No: |  |\n| DOB: | COB: |  | Sex: ☐ Male ☐ Female |\n| Is the client Aboriginal / Torres Strait Islander:\u003Cbr>☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Neither Aboriginal nor Torres Strait Islander ☐ Unknown |  |  |  |\n| Address: |  |  |  |\n| Phone Number: |  |  |  |\n| Email: |  |  |  |\n| Interpreter Required: ☐ Yes ☐ No |  | Language: |  |\n| Alternate Contact: |  | Relationship: |  |\n| Phone Number: |  | Email address: |  |\n| Preferred person to contact for appointments: |  |  |  |\n| General Practitioner: |  | Phone: |  |\n| Address: |  |  |  |\n| Relevant Health Information (Attach PM Hx medical/initial reason for admission to hospital/discharge/medication summaries) |  |  |  |\n\nCommunity Rehabilitation ServiceReferral Form  \nFAMILY NAME   MR N   GIVEN NAME   􀂅MALE 􀂅FEMALE DoB   /   /   M. O   ADDRESS    \nLOCATION/WARD   COMPLETE ALL DETAILS OR AFFIX CLIENT LABEL HERE  \n\n| Current Functional Status:\u003Cbr>Self-Care: ☐ Independent ☐ Assistance Required Equipment used:\u003Cbr>Transfers: ☐ Independent ☐ Assistance Required Equipment used:\u003Cbr>Indoor Mobility: ☐ Independent ☐ Assistance Required Equipment used: Outdoor Mobility: ☐ Independent ☐ Assistance Required Equipment used: Stairs: ☐ Independent ☐ Assistance Required Equipment used:\u003Cbr>Comments: |  |  |\n| --- | --- | --- |\n| Orthopaedic Restrictions / Precautions (if relevant):\u003Cbr>☐ WBAT ☐ Partial WB   % ☐ Protected WB ☐ NWB\u003Cbr>Date Commenced: Timeframe of\u003Cbr>restrictions:\u003Cbr>Next ortho review date: Surgeon details: | ☐ Other | ____________ |\n| Falls risk: ☐ Yes ☐ No If Yes, provide details: |  |  |\n| Pressure Injury risk: ☐ Yes ☐ No If Yes, provide details: |  |  |\n| Communication issues: ☐ Yes ☐ No If Yes, provide details: |  |  |\n| Nutrition issues: ☐ Yes ☐ No\u003Cbr>Weight   kg Height   cm Weight change in last 6-12 months   Recent loss of appetite ☐ Yes ☐ No If Yes, provide details:\u003Cbr>Modified Diet ☐ Yes ☐ No If Yes, provide details: |  |  |\n| Cognitive issues: ☐ Yes ☐ No If Yes, provide details: |  |  |\n| Social issues: ☐ Yes ☐ No If Yes, provide details: |  |  |\n| Social situation: |  |  |\n| Pre-existing mental health or drug and alcohol history that may impact on their rehab program? Please tick and outline below:\u003Cbr>☐ Low mood ☐ Unstable Mood ☐ Anxiety/Panic attacks\u003Cbr>☐ Low motivation ☐ Aggression ☐ Disinhibition\u003Cbr>☐ Psychosis ☐ Drug and/or alcohol history ☐ Other… Provide details:\u003Cbr>Comments: |  |  |\n\nCommunity Rehabilitation ServiceReferral Form  \nFAMILY NAME   MR N   GIVEN NAME   􀂅MALE 􀂅FEMALE DoB   /   /   M. O   ADDRESS    \nLOCATION/WARD   COMPLETE ALL DETAILS OR AFFIX CLIENT LABEL HERE  \n\n| Reason for Referral / Client Goals: |  |\n| --- | --- |\n| Any Other Services Involved / Organised for Client (include contact details): |  |\n| Referring Agency: | Name & Designation: |\n| Phone number: | Contact email: |\n\nCRS Office Use Only  \n\n| Date Received: | Date Admitted: | Code: |\n| --- | --- | --- |\n| CMS Clinic: |  |  |\n\nInformation about the programs and","cbCaidz606UTbrkz","https://ap.wps.com/l/cbCaidz606UTbrkz","pdf",114703,"English","# Service Referring to\n## Services requested\n## Referral dates\n# Client information\n## Demographics and identifiers\n## Contacts and interpreter needs\n# Health and functional details\n## Relevant health information\n## Current functional status\n## Orthopaedic restrictions and precautions\n## Risk and clinical issues\n# Goals and referring agency\n## Reason for referral and client goals\n## Other services involved\n# CRS office use only\n## Dates and codes","[{\"question\":\"Which services can be requested on this referral form?\",\"answer\":\"Dietitian, Social Work, Nursing, Neuropsychology, Occupational Therapy, Physiotherapy, Speech Pathology, and Aquatic Physiotherapy (outpatients only) can be selected.\"},{\"question\":\"What patient and referral details are required?\",\"answer\":\"The form requests family name, MR number, given name, sex, date of birth, contact information, interpreter requirements, referring agency details, date referred, and expected discharge date.\"},{\"question\":\"What clinical risk and functional information does the form collect?\",\"answer\":\"It captures current functional status, orthopaedic restrictions/precautions, falls risk, pressure injury risk, communication, nutrition, cognitive, and social issues, including relevant details when risks or issues are selected.\"}]","CRS-Referral HBR OPD Jun25 - Referral Form | PDF",1789844156]