Therapy at Home Screening Checklist



| |Early Supported Discharge (Stroke) |

|Early Supported Discharge Service for Stroke |West Hertfordshire |

|REFERRAL FORM |The Avenue Clinic |

|& SCREENING CHECKLIST |The Avenue |

| |Watford |

| |Hertfordshire |

| |WD17 3NU |

| |Tel: 01442 454 871 |

| |Fax: 01442 453 125 |

|Criteria Checklist | |

|(Please Tick Boxes): | |

|Registered with a GP in West Herts: |Has adequate level of cognition to maintain |

| |own safety when at home alone: |

|>18 years: | |

|Primary diagnosis of stroke: |Home environment suitable for rehabilitation: |

|Medically stable for discharge: | |

|Transfer safely with assistance of 1: |Able to safely administer medication on |

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