Funding Source for Equipment

VIDEO CONFERENCE APPOINTMENT BOOKING FORM

Referrer Details
Name: / Date of referral:
Role: / Organisation:
Phone: / Email:
Mobile Phone: / VC Room Phone:
Reason for Referral:
Notes:
Client Details
Name: / Gender:
Date of Birth: / Age:
Diagnosis:
Primary Contact: / Relationship:
Phone: / Email:
Address: / Postcode:
Country of Birth: / Main language spoken at home?
Interpreter required: Yes/No
Communication Impairment: Yes/No
If ”Yes”, provide details: / Alternative/augmentative communication device (and type): Yes/No
If ”Yes”, provide details:
Is the person of Aboriginal or Torres Strait Islander Descent?
Aboriginal: Yes/No
Torres Strait Islander: Yes/No
Aboriginal and Torres Strait Islander: Yes/No
Notes:
Other Attendees
Name:
Role:
Phone:
Email: / Permission obtained to contact: Yes/No
Attending at ILC /or via VC
Notes:
Name:
Role:
Phone:
Email: / Permission obtained to contact: Yes/No
Attending at ILC /or via VC
Notes:
Name:
Role:
Phone:
Email: / Permission obtained to contact: Yes/No
Attending at ILC /or via VC
Notes:
Will the client attend at ILC/ or via VC? / Will the DSC Country Resource Team attend at ILC/ or via VC?

EQUIPMENT DETAILS

Funding Source for equipment:

Equipment to be looked at during the appointment:

G:\General Client Services\Appointment Bookings and Requests\Country appointments referral form.doc

VIDEO CONFERENCE APPOINTMENT BOOKING FORM

G:\General Client Services\Appointment Bookings and Requests\Country appointments referral form.doc

VIDEO CONFERENCE APPOINTMENT BOOKING FORM

What equipment are they using now?

Is this working/not working, and if not, why not?

Are there any specific pieces of equipment that are requested?

Equipment Name / Model / Requested size / Options/Accessories
Forpower wheelchairs specify:control type,body part used to drive, left or right hand control (if relevant)

Client dimensions:

Height: / Seat width: / Other relevant dimensions:
Weight: / Seat depth:
Heel to popliteal:
Back height (to top of head):

Additional Information (e.g. environment where equipment is to be used, transport methods):

How often does the client travel to Perth?

What other appointments does the client have scheduled for this trip and on the day (including ILC Tech appointments)?

Is a preliminary videoconference or teleconference to assist in equipment selection or any other preparation for the appointment desired? Yes/No If ”Yes”, requested date(s) and time(s) for this:

Requested date(s) and time(s) for appointment:

Role you would like the ILC staff member to fulfil during the appointment:

Lead therapist for appointment: Yes/No

Any other role you would like us to take:

ILC Office use only:

Videoconference/Teleconference booked: Yes/No Date(s):

N.B. Please book a minimum of 1.5 hours for all VC appointments and longer if a preliminary consult on the day or multiple equipment areas are requested.

Please advise all parties as to the length of the appointment booked.

G:\General Client Services\Appointment Bookings and Requests\Country appointments referral form.doc