Client Referral Form

    PART 1

    ELIGIBILITY DECLARATION

    Part 1

    COVID -19 Declaration
    Have you had the COVID-19 Vaccine ?*
    Yes - fully vaccinatedNo

    Your client does not qualify to use our transport services.
    PLEASE DO NOT PROCEED FURTHER

    Please email vaccination verification to info@sirroden.org.au

    Veteran Affairs and/or Workcover
    Do they have a Department of Veteran Affairs card (DVA) or are under Workcover?*
    YesNo

    Your client does not qualify to use our transport services.
    PLEASE DO NOT PROCEED FURTHER

    Does the client require intervening treatment, intravenous therapy or monitoring whilst in transit?*
    YesNo

    Your client does not qualify to use our transport services.
    PLEASE DO NOT PROCEED FURTHER

    PART 2

    Part 2

    If you answer NO to any of the following questions below, your client does not qualify to use our transport services. PLEASE DO NOT PROCEED FURTHER

    Are they receiving an aged/disability pension?*
    YesNo

    Enter Pension number (if applicable):

    Your client does not qualify to use our transport services.
    PLEASE DO NOT PROCEED FURTHER

    Is your Client attending important medical appointments?*
    YesNo

    Your client does not qualify to use our transport services.
    PLEASE DO NOT PROCEED FURTHER

    Has the client any other transport options (e.g. Family & Friends) available to them?*
    YesNo

    Your client does not qualify to use our transport services.
    PLEASE DO NOT PROCEED FURTHER

    Is well enough to travel unassisted in a domestic vehicle, in a seated position and without medical personnel on board?*
    YesNo

    Your client does not qualify to use our transport services.
    PLEASE DO NOT PROCEED FURTHER

    If your client is in a Wheelchair is he/she able to manuovre themselves without assistance or alternatively be accompanied by a carer to assist with the transport.*
    YesNoNot Applicable

    Your client does not qualify to use our transport services.
    PLEASE DO NOT PROCEED FURTHER

    PART 3

    Part 3
    Referred and Completed by

    Must be completed by a Medical Practitioner/Professional or Hospital based social worker.

    Organisation name*

    Referred First Name*
    Last Name*
    Position

    Contact person*
    Contact person E-mail*
    Contact person phone number (incl area code)*

    CLIENT DETAILS

    CLIENT DETAILS

    First Name*

    Last Name*

    Date of birth*

    Day

    Month

    Year

    Gender* MaleFemale
    Address*
    Suburb

    City

    State

    Postcode

    Country

    Phone number*
    Mobile number
    E-mail*

    Pension* AgedDisability support
    Emergency contact Person*
    Emergency contact relationship
    Emergency contact phone number*
    Living Arrangement
    Lives aloneLives with familyOther
    Does the client have a carer? NoYes

    TRIP
    DETAILS

    TRIP DETAILS

    Purpose of Trip*

    Pick up time (8.30am earliest)*

    Day

    Month

    Year

    at Hour

    Minutes

    AMPM

    Return trip (4.00pm latest)*

    Day

    Month

    Year

    at Hour

    Minutes

    AMPM

    Going to - doctor/hospital:
    Street Address
    Suburb
    City

    State

    Postcode

    Country

    Will this be a regular trip? NoYes

    SPECIAL NEEDS

    SPECIAL NEEDS

    Ability to get places further than walking distance*
    Without helpWith some helpCompletely unable
    Ability to walk*
    Without helpWith some helpCompletely unable
    Does the client use a walking aid*
    NoWalking stickWalking frameWheel chair
    Does the client have memory confusion problems*
    NoYes
    Does the client have behavioural problems*
    NoYes

    Please state any relevant health issues that our driver should be aware of:
    e.g. hearing, allergies, incontinence, diabetes etc:

    WH & S ISSUES

    WH & S ISSUES

    Can the client get themselves independently to and from the car to their home?*
    NoYesWith Help
    Can the client manoeuvre in and out of a car?*
    YesNoWith Help
    Can the client manage alone once at the destination?*
    YesNoWith Help

    Is a carer going to accompany the client?*
    YesNo
    Can the client transfer from wheelchair?*
    YesNo

    ADDITIONAL INFORMATION

    ADDITIONAL INFORMATION

    Please enter any comments or additional information


    COVID-19 UPDATE