ACA Referral – About Care Australia

ACA Referral

Thank you for choosing and trusting us to provide you with the care you need to live a quality life. To commence your journey with About Care Australia, a referral form will need to be submitted.

The referral form will provide us with vital information on your; or your client’s goals and care needs. The information will be used to help us to allocate the most suitable clinical or non clinical support you require.

Please complete all the information to ensure you get the services you need. There is choice of PDF or word referral, if you get stuck, we are here to assist you. Someone will contact you regarding engagement of services

Referral Form

It is essential we receive copies of recent clinical correspondence with this form for clinical referrals

Patient Details

Surname

First Name

Address

Post Code

Tel

Date of Birth

Age

Ethnicity

Main Family or NOK of Patient

Family or NOK Name

Family or NOK Telephone Number

Family or NOK Address

Post Code

Relationship to Patient

Party responsible for Account

Invoices to Be Emailed to

Accommodation

Supported Independent Living Individual Living Option (ILO) Specialist Disability Accommodation (SDA) Short term/ respite accommodation

Urgent? - complex symptoms/rapidly changing situation, (contacted and seen within 48 hours)

Yes No

If patient not seen within 48 hours, is there a risk of hospital admission?

Yes No

Routine? - no immediate pressing issues, (contacted within 2 days and seen within 10 days)

Yes No

Any access issues? (please state)

Key safe number

Is anyone at the client’s property known to be aggressive or violent?

Yes No

Are there any firearms located at the property?

Yes No

Are there any occupants who have an infectious disease (i.e. chicken pox/ shingles/ gastro, Covid- 19 symptoms etc.)?

Yes No

Are there any risks related to pets or animals on the premises?

Yes No

Are there any other factors we should be aware of visiting this client at home on our own?

Yes No

Current Issues for About Care Australia intervention

Past Medical and Mental Health History

General Practitioner is GP aware of referral?

Yes No

GP Name

GP Telephone

GP Address

Any other comments/useful information

Please ensure patients are aware information will be held on computer according to the General Data Protection Regulation.

Referrer's Name

Date

Job Title

Referrer's Telephone

I Accept Terms & Conditions

Book an Appointment

Name

Phone

Service

Message

Select Date

Select Time

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