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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