FOR OFFICE USE ONLY
Date of referral                  Priority  1    2    3

See by date                                      

 AUID	
Surname <PtSurname>	
First name <PtFirstName>	

REFERRAL FORM
Blue Mountains Nepean
Aged Care Assessment Team
Telephone 1800 557 178
Fax (02) 4734 3903 

D.O.B. <PtDoB>	Age <PtAge>	Sex <PtSex>	
Address <PtStreet>	
Suburb <PtCity>	Postcode <PtPostcode>	
Phone <PtPhoneH>	
Current Address (if different)  <Current Address>	
Community assessment <Community Assessment>
Hospital inpatient assessment <Hospital Assessment>   
<Hospital>	
IMPORTANT:  To be eligible for an ACAT assessment the following criteria must be met.  (tick all that apply)	
<ACAT Assessment Criteria>                                                                                                                                                                                                                                                                                                                                                                             
A referral for a younger person with a disability can only be accepted when all other age appropriate accommodation and support/services have been exhausted. Additional written evidence is required                                                          	
Referrer Details
Name: <Referrer Name>      Relationship: <Relationship>      Tel: <Referrer Telephone>       Alt Tel.: <Referrer Alt Telephone>                                                                  	
Country of Birth: <Country of Birth>      
Interpreter Required? <Interpreter Required?> Language: <Interpreter Language>
ATSI Status: <ATSI Status>
Marital Status: <PtMaritalSt> 
Income: <Income> DVA Card: <PtDVACard>  
Medicare Number: <PtMCNo>  
DVA Number: <PtDVANo>                                         
	
Contact (for appointment): <Contact (for appointment)>                                                                                                                    Name: <Name of Contact for Appointment>    Relationship: <Relationship>    Tel: <Telephone>    Alt. Tel:  <Alternative Telephone>                                                                        	

Practice Stamp

General Practitioner
Name: <DrName>
Street Address: <DrStreet>
Suburb: <DrCity>         Postcode: <DrPostcode>
Phone: <DrPhone> Fax: <DrFax>

      

                                      	
Presenting Problems or Issues (reason for referral)
<Reason for Referral>

Care Situation
<Care>
   	
Medical Conditions
 <SelectedPMH>

<Cognitive>     <MMSE Score>

(Please attach a health summary if available)	
	
Mobility
<Mobility>
	
Social Situation
<Social Situation>

	Falls Screen
<Falls Screen>

	Other Concerns
<Other Concerns> 	
Concerns Checklist	
<Concerns Checklist>

			
Current services/support
<Current services/support>

<Is there a case manager?>
	
Comments
<Comments>

	

FOR OFFICE USE ONLY
First Intervention?   No
  Yes, details

Intake Officer 

Referral Accepted     Yes    No, reason ___________________________________________________________________
                             
  ACE     CHIME     Scanned     Waitlist letter sent     Waitlist letter not required