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Aged Care Referral

Client Details
Client Name
Client Gender
Client Address
Home Care Information
Clinician Required
Do you have a current Home Care Package?
Where are you requesting services to take place?
How is your Home Care Package managed?

You have selected self managed. Please provide an email address to where invoices are to be sent.

Contacts
Next of Kin
Contact Person's Relationship to Participant

Who is your case manager or service coordinator?

Service Coordinator/Key Contact

If you are not the Next of Kin or the case manager/service provider - please fill in the below information

Who is making the referral?
Safety

In order for this referral to be completed please provide information regarding any safety concerns.

Does the client have any behaviours of concern? *
Are there any pets at the clients residence? *

Please provide additional information if there are any safety concerns we should be aware of when accessing your property.

Does the client have a history of substance abuse? *

Illicit drugs and/or alcohol

Does anyone at the residence have a criminal history? *
Are you aware of any firearms being stored at the property? *
Are there any environmental risks we need to be aware of? *

Please specify if there are any environmental risks and/or if there is adequate space in the home.

Are there any communication needs we need to be aware of? *

ie will a interpreter be required, is English a second language, is the participant non-verbal

Will anyone else be present during the appointment? *
Does any of the residence have any health concerns? *

ie cold/flu symptoms / COVID / gastro / infections diseases

Has anyone at the residence been known to be aggressive/violent? *
Form Completion

Form Upload

How did you hear about Flex Care?  *
Client Details
Client Name
Client Gender
Client Address
Home Care Information
Clinician Required
Do you have a current Home Care Package?
Where are you requesting services to take place?
How is your Home Care Package managed?

You have selected self managed. Please provide an email address to where invoices are to be sent.

Contacts
Next of Kin
Contact Person's Relationship to Participant

Who is your case manager or service coordinator?

Service Coordinator/Key Contact

If you are not the Next of Kin or the case manager/service provider - please fill in the below information

Who is making the referral?
Safety

In order for this referral to be completed please provide information regarding any safety concerns.

Does the client have any behaviours of concern? *
Are there any pets at the clients residence? *

Please provide additional information if there are any safety concerns we should be aware of when accessing your property.

Does the client have a history of substance abuse? *

Illicit drugs and/or alcohol

Does anyone at the residence have a criminal history? *
Are you aware of any firearms being stored at the property? *
Are there any environmental risks we need to be aware of? *

Please specify if there are any environmental risks and/or if there is adequate space in the home.

Are there any communication needs we need to be aware of? *

ie will a interpreter be required, is English a second language, is the participant non-verbal

Will anyone else be present during the appointment? *
Does any of the residence have any health concerns? *

ie cold/flu symptoms / COVID / gastro / infections diseases

Has anyone at the residence been known to be aggressive/violent? *
Form Completion

Form Upload

How did you hear about Flex Care?  *