Whittlesea Connect Community Transport Service
Agency Referral Form
Access to the service is by referral only. This form must be completed by aDoctor or Nurse,community, health/welfare, social services worker or family member.
(Please read WhittleseaCommunity Transport Service brochure when filling in referral)
Please see community transport brochure for details about the service:
REFERRAL DETAILS
Date: ___/___/______NEW CLIENT or EXISTING CLIENT: ______
Active Inactive/discharge date: ___/___/____
CLIENT DETAILS MELWAY REF:
Family Name: ______Given Name: ______Preferred Name: ______
Sex: Male FemaleTitle: Mr Mrs Ms Miss Other (Please specify ): ______
Date of Birth: ___/___/____ is the client registered with DHS? Yes No Has DSR? Yes No Not sure
Address: ______Phone Number: ______Mobile: ______
PRIMARY CONTACT DETAILS /CARER DETAILSAlso primary carer
Family Name: ______Given Name: ______Preferred Name: ______
Sex: Male FemaleTitle: Mr Mrs Ms Miss Other (Please specify ): ______
Date of Birth: ___/___/____ Relationship to client: ______Carer for more than 1 person Yes No
Address: ______Phone Number: ______Mobile: ______
Country of Birth: ______Language: ______Indigenous Status:
Neither Aboriginal nor Torres Strait Islander Aboriginal but not Torres Strait Islander
Torres Strait Islander but not Aboriginal Both Aboriginal & Torres Strait Islander
Does the client require assistance getting to and from vehicle or in and out of vehicle? / YES / NODoes the client use a mobility aid?
Stick Walking Frame other: ______
Is the client a wheelchair user? If yes, please tick box below:
Note: If the wheelchair has side panels, these must be able to be lifted up for the client to be transported / YES / NO
Transport Disadvantage / Please circle to indicate below how your client is transport disadvantaged?
Does the client have a car? YES NO Does the client have a licence? YES NO
Does the client have family available to take them? YES NO Are they able to take public transport? YES NO
Please explain why community transport is needed.
Is the client travelling with children? If yes, please fill in below:Child 1 DOB: Approx Child’s weight (kg’s) ______
Child 2 DOB: Approx Child’s weight (kg’s) ______/ YES / NO
Will your agency be making a donation on behalf of your client?
While this is not compulsory, the Community Transport Service is an unfunded service and it’s continuance will depend on contributions being made by agencies who regularly use the service to support their clients (invoices and receipts can be provided on request) / Yes
Donation amount / No
$ ______
Please return completed form by mail
Whittlesea Connect Community Transport Service
Whittlesea Community Connections
571-583 High St, Pacific Epping, High Street, Epping 3076
Phone: (03) 9401 6666
Email: / Office Use Only
Client HACC eligible Yes No
Client Transport HACC eligible Yes No
Referred to alternative service Yes No Referred to: