MetroNorthHospital & Health Service
Subacute and Ambulatory Service
Community Based Rehabilitation Team Referral / (Affix patient identification label here)
URN:
Family Name:
Given Names:
Address:
Date of Birth:Sex: M F
ATTACH A DISCHARGE /MEDICAL SUMMARY TO THIS REFERRAL
Client Consent
Yes No Reason if No Date of Referral
Is the Client Motivated
Yes No Reason if No
Diagnosed Related to Referral Date
Stoke
Brain Dysfunction/Trauma
Neurological Conditions
Orthopaedic Conditions
Spinal Cord Dysfunctions/Trauma
Amputation (note where)
Other Disenabling Impairment
Current Functional Status(help needed with) 0-None 1-Minimal 2-Moderate 3-Substantial
(drop down box under status 0-None 1-Minimal 2-Moderate 3-Substantial)
FunctionStatus Aids Used Function Status Aids Used
HygieneYes No Dressing Yes No
Grooming Yes No Mobility Yes No
StairsYes No Upper Limbs Yes No
Lower LimbsYes No Bladder Yes No
BowelYes No Toileting Yes No
FeedingYes No Swallowing Yes No
CommunicationYes No Memory Yes No
DrivingYes No Access to Transport Yes No
Additional Information
Has the client had recent rehabilitation? Yes No
Location (drop down box Inpatient, outpatient) Where Dates to
Has the client been given a HEP Yes No
Does the client live alone Yes No Cognitive Score /30(drop down box MMSE, RUDAS)
Referral to (Tick all that apply)
Occupational Therapist Physiotherapist Leisure Therapy Social Worker Speech Pathologist

Medical Issues

Social Issues
Other Services Involved (State who is involved and how often the service is provided)
Other Services Involved (State who is involved and how often the service is provided)
Multi-Disciplinary Goals and Issues

Referrer Details

Name Address/Agency/Practice

Telephone Fax

Email Address

Hospital Details (if applicable)

Hospital & Ward Consultant Name Admission Date Discharge Date

Client Details

Title Name Sex M F Date of Birth

Address

Telephone Mobile

Indigenous Status(drop down box Aboriginal/Torres Strait Islander/Both Aboriginal and Torres Strait Islander/Non-Indigenous)
Does the client require an interpreter? Yes No Unknown If yes, language spoken
Medicare No Expiry Date
Government Benefit Card No
(drop down box No Benefit/Aged Pension/Carers Pension/Disability Pension/Unemployment Benefit/Veteran White/Veteran Gold)
Health Insurance Card No Company
(drop down box None/Hospital Only/Extras Only/Hospital & Extras/3rd Party/Workers Compensation Motor Vehicle)
Emergency Contact
Name Address
Telephone Mobile
Relationship to Client
Does the client have an EPOA? Yes No Unknown
EPOA Name Telephone
REFERRAL SUBMISSION
BrisbaneCity Council area MoretonBay Regional Council area
Fax: 3139 6522 Fax: 3049 1260
Enquiries: 1300 658 252 Enquiries: 1300 658 252

Page 1 of 2