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