REFERRAL
		Community Aged Care & 				Rehabilitation Service (CARS)

			Phone:  1800 260 464
			Fax:   (03) 6222  7165
			Email:  cars@dhhs.tas.gov.au	<PtName>
DOB. <PtDoB>	
	REFERRAL TO:	SERVICE REQUESTED:	
	q	Aged Care Assessment Team (ACAT)	

q	Community Rehabilitation Unit (CRU)	

q	Day Rehabilitation Unit  (DRU)	

q	Concussion Unit  (DRU)	

Other: 	q	Rehab Medical 	
q	Physiotherapy 	

q	Rehab Nursing 	
q	Social Work 	

q	Occupational Therapy 	
q	Dietics 	

q	Speech Pathology 	
q	Psychology 	

Other:	

CLIENT DETAILS	 CONSENT DETAILS:	
	Patient ID: 	 Client consents to referral? 	 <Client consents to referral>	
	Hospital Discharge Date: 	 Client has capacity?			<Client has capacity to consent>	
Title: 	<PtTitle>	  Determined by:  	<Capacity to Consent determined by> 	
Family Name:		<PtSurname>	  Key Contact Person  (if not client)	
Given Name/s:	<PtFirstName>	  Name:		<Key Contact Person (if not client) Name:>	
Preferred Name/s:   <PtPrefName>	  Address: 		<Key Contact Address>	
Date of Birth:   	<PtDoB>	  Phone: 		<Key Contact Phone>	
Sex:			<PtSex>	  Relationship to Client:  <Key Contact Relationship to Client>	
	  Is Carer:		<Is this person the Carer>  	
 ADDRESS DETAILS:	  GENERAL PRACTITIONER: 	
  Usual Address: 	Name: 	<DrName>	
  <PtAddress>	Address:  	<DrAddress>	
  Current address:  	<Patient Current address (if not the usual one)>	 	Phone: 	 <DrPhone> 	
  (if different from above)	Fax:   		<DrFax>	
Client lives:	<Patient living situation>	Email: 		 <DrEmail>	
  CONTACT DETAILS	ETHNICITY:	
Can leave message?  x	  Country of Birth:		<Country of Birth>	
Home:		<PtPhoneH>			q	  Indigenous status:		<Indigenous status>	
Work:		<PtPhoneWk>			q	  Language:			<Language>			
Mobile:	<PtPhoneMob>		q	  Other language:		<Other Language>	
Fax:					q	  Interpreter required?	<Interpreter Required>	
Email:		<PtEmail>			q 					<Interpreter Gender Preference>	
  SOURCE of REFERRAL	 PENSION STATUS	
Name: <DrName>	Card type: 			<Pension Card Type>	
Relationship to Client:	Personal GP	Pension Card Number:	<PtPensionNo>		
If other, please specify: 	Medicare Number:	 	<PtMCNo>	
Address:/Phone  As in General Practitioner Details	Health Care Card Number: <Health Care Card Number>			
  DVA CARD STATUS	  INSURANCE STATUS	
 Card Type: 		<PtDVACard>	Insurance Type:		<PtHealthIns>	
DVA Card Number:	<PtDVANo>	Health Insurer Name:	<PtInsFund>
Insurer Card Number:	<PtInsNo>	

	 MEDICAL DIAGNOSIS and HISTORY	
	<SelectedPMH>

	  DESCRIPTION OF PROBLEMS/ISSUES IDENTIFIED BY CLIENT/REFERRER:	
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	 CURRENT SERVICES  (RECEIVED WITHIN LAST THREE MONTHS):	
Service Type:	Service Provider Name:	Phone Number:	

			
			
  REHABILITATION GOALS (IF APPLICABLE)	
  Transport assistance required  (if available) ?		q	Yes	q	No	

	
  ALERTS:	

  ADDITIONAL COMMENTS:	

	
Name:  <DrName>	

Signature: 									Date:   <TodaysDate>	

<Note> <..>