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
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
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 involved
Contact 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 by
Name of worker: / Role:
Organisation:
Postal address: / Suburb: / Postcode:
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: / To discuss this referral please contact
Gateway Services on (03) 9815 7800
Connecting Care members can choose to send referrals via a secure connection at http://www.connectingcare.com
Page 3 of 3