Older Persons Mental Health Service Referral Form - Cairns And Hinterland
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CAIRNS
HINTERLAND
HOSPITAL & HEALTH SERVICE
PO Box 6515
Cairns Qld, 4870
OLDER PERSONS
Ph: 4226 5266
MENTAL HEALTH SERVICE
Fax: 4226 5299
REFERRAL FORM
Date:
Surname: ___________________________
Given Name: _____________________
D.O.B: _____________________________
Gender:
Male
Female
Residential Address: _________________
Phone Number: __________________
___________________________________________________________________________
Next of Kin/Main Contact Person:_____________________________________________
__________________________________________________________________________
Accommodation Type:
Pvt Residence
Hostel
Res Aged Care Facility
Other
Lives alone:
Yes
No Access Hazards: ______________________________________
Marital Status:
Married
Widowed
Never married
Separated
Divorced
Not stated/unknown
Defacto
Indigenous Status:
Aboriginal
Torres Strait Islander
Non Indigenous
Unknown/Not stated.
Preferred Language: _________________________
Interpreter:
Yes
No
Previous Contact with this Service:
Yes
No.
GP Referrer Details: ______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Phone ________________________________
Client informed of referral
Yes
No
Family informed of referral
Yes
No
Is client known to Aged Care Assessment Program:
Yes
No
Reason for Referral:
Psychiatric Assessment & Recommendation only.
Short term review.
Medication review.
Behavioural management strategies.
Other ______________________________________________________________________
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Parent category: Medical