Care Finder Service Referral Form - Country & Outback Health

care finder
Referral Form

Please complete all information required in the form fields below

Care Finder Referral Form

Client Details

Title

First Name *

Middle Name

Last Name *

Gender

Date of Birth / Estimated DOB *

Is the client an NDIS Participant / Does the client have a Disability?
NDIS Participant
Has a disability
Both
Neither

Please provide details of NDIS / Disability

Address *
Address Line 1
City
State / Province / Region
Postal Code
The service is only available within South Australia. Check our services page for specific locations. Or contact Head to Health directly on 1800 595 212 or visit website www.headtohealth.gov.au for alternative services in their area.

Phone (Home) *

Phone (Mobile)

Interpreter Required?
Yes
No

Aboriginality
Aboriginal
Torres Strait Islander
Both

Are there any cultural considerations to consider when assigning a care finder?
Yes
No

Emergency Contact

Name

Relationship

Phone

Referral Details

Date of referral

Referrer Name

Referrer Phone

Referrer Email

Referrer Town / Suburb

Reason for Referral

Client is eligible for My Aged Care *

Yes No Unsure

YesYes
NoNo
UnsureUnsure

Yes	No	Unsure
YesYes	NoNo	UnsureUnsure

Has the client ever had an ACAT/RAS assessment? *

Yes No Unsure

YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
UnsurePresent in last 4 weeks Unsure

Yes	No	Unsure
YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No	UnsurePresent in last 4 weeks Unsure

The client meets the eligibility criteria for accessing the care finder type services *

Yes No Unsure

YesPresent in last 4 weeks Yes
NoPresent in last 4 weeks No
UnsurePresent in last 4 weeks Unsure

To be eligible for these care finder services, the client needs to be unable to navigate My Aged Care services on their own and does not have any family members/community members that can assist them in navigating My Aged Care services

Yes	No	Unsure
YesPresent in last 4 weeks Yes	NoPresent in last 4 weeks No	UnsurePresent in last 4 weeks Unsure

Signature of Referrer

Signature of Referrer

Website

care finder Referral Form