XXX PRIMARY CARE TEAM - Physiopedia



PCCC Referral Form

Please ensure all sections complete & consent received from Client or Parent / Guardian

|Client Name |

| |      |DOB |  |  |  |

|Address | | | | | |

| |      |Gender | Male Female |

|Tel/Mobile # |      |Consent to receive Text messages? | Yes No |

|Parent/Guardian/ NOK |      |GP Name (or stamp) |      |

|Relationship to client |      |Address |      |

|Tel / Mobile # |      |Tel # |      |

|Public patient card type: |      | |      |

| | |Card # | |

|Referral from Acute Services |Private Insurance |Yes No |Provider |      |

|If facilitating hospital discharge, date of discharge |    /    /     |Hospital Medical Record # |      |

| |

| Referral To |Tick box for discipline(s) you are referring to |

| | |

|Health & Social Care Professionals (PCT / HSCN) |Specialist Teams / Services |

| | | | | |

|GP |Area Medical Officer Audiology|Dental Services |Asylum Seekers Service |Mental Health Services |

|Practice Nurse |Carers Service |Dietitian |Child & Family Services |Older Persons Services |

|PHN |Chiropody/Podiatry |Ophthalmology |Disability Services |Palliative Care |

|RGN |CMHN / CPN |Psychology |Early Intervention Team |Population Health |

|OT |Counselling |Other Refer to Directory of |Health Promotion |Substance Misuse |

|Physio |CWO |Services to specify: |Homeless Services |Other Refer to Directory of Services |

|SLT | | | |to specify: |

|Social Work | |                     | | |

|Home Help | | | |                     |

| | |

|Reason for Referral |      |

|Please be specific | |

| | |

|Relevant History/ Issues of |      |

|Concern | |

| | |

|Medications |      |

| | | | | |

|Social Circumstances |Live alone? |Yes No |With whom? |      |

| | | | | |

| |Interpreter required? |Yes No | | |

| | | | |      |

| | | |Language | |

| | Independent | With Aid | Wheelchair | Immobile |

|Mobility | | | | |

|Other professionals involved in client’s care? Yes No Don’t know If “yes” provide name & contact details |

|Has Client (or parent/guardian) consented to this Referral? | Yes No |

|Has Client (or parent/guardian) consented to sharing of His/Her information? | Yes No |

| |Name / Title |      |Date |    /    /      |

|Referred By | | | | |

| |Signature |      |Tel # |      |

| | Fax |      | Email |      |

|Preferred method of contact: Telephone | | | | |

| |      |

|PCT / HSCN / OOH Co-op / Hospital Dept | |

|Client Name:       |DOB:    /    /     |PPSN:       |Page 2 |

Essential Information for Discipline Referrals

This is not an assessment form; it is for the purpose of Interdisciplinary Referral ONLY

CHILD & ADOLESCENT REFERRALS

|All Referrals |

|Public Health Nurse Report Available? Yes No |

| |      |Class |      |

|School attending | | | |

|Audiology – Hearing Test |

|Date tested |1)    /    /      |2)    /    /      |

| | |RIGHT Pass REFER | |LEFT Pass REFER | RIGHT Pass REFER |

| |LEFT Pass REFER | | | | |

|Area Medical Officer / Nursing |

| Vision | Hearing | Behaviour | Parental Concern |

| Height / weight | Nutrition | Developmental Delay | Child Welfare |

| Other |      |

|Social Work - In case of Emergency, contact should be made with An Garda Siochana |

| Child Protection/Welfare Concerns | Children in Care | Family Support | Early Intervention | Other |

| |      |

|Care and Custody arrangements regarding child, if known: | |

ALL REFERRALS

| |

|CWO / Social Work Detail family size & circumstances in Relevant History section |

| Accommodation | Community Links | Independent Living | Other state services/schemes |

|Allowances / grants |Finances |Information service |Social Needs |

|Carer Support |Home repairs / refurbishment |Med Card application/review |Other:                 |

| |

|Dietetics Attach full biochemistry report if available including: Na, K, Urea, Creat & Urinary Albumin. Please note fasting or non-fasting |

|Height |

| Continence problem | Home Supports | Preventive / Anticipatory Care |

|Chronic Illness Management |Leg ulcer / pressure care / wound care |Psychological Support |

|Health Education / Promotion |Nursing assessment | |

| | | Other: |      |

|Existing Pressure Sore | Yes No |

|Assessments: |

|Snellen Visual Acuity (at 20ft/6m) Distance VA {R}      VA {L}      Near VA {R}       VA {L}       |

| |

|Physiotherapy & Occupational Therapy Attach copies of X-rays, MRI, DEXA scans, etc if available |

|How long has the client had complaint? | 1-2 Weeks 2-4 Weeks 1-3 Months 3-6 Months 6+ Months |

|Is the problem getting | Better Worse Unchanged |Night pain: | Yes No |

| | Yes No |

|Is the client experiencing functional limitations with condition? eg activities of daily living, off work, etc. | |

|Difficulty with transfers | Bed | Chair | Toilet |

| |

|Psychology (Child, Adult & Disability) Fully detail psychological concern(s) you identify below in the Relevant History Section |

| Emotional Concerns | Behavioural Concerns | Cognitive Impairment | Abuse (Type): |      |

| Physical & Chronic Illness | Relationships / Family | Disability Act (AON) | Risk: |      |

| School Concerns | Psycho-social Concerns | Other |      |

| |

|Speech & Language Therapy |

|Communication Issue: | Recent | Reoccurrence | Developmental |

|Feeding, Eating, Drinking or Swallowing (FEDS) issue: | Recent | Reoccurrence | Developmental |

|Involves: | Understanding | Speech | Voice | Expressive language |

| | AAC (augmentative/alternative communication) | Other:       |

| |

|Retain a copy of this form for record keeping & audit purposes |

PCCC Referral Acknowledgement

Please acknowledge that you received the Referral by completing and signing below,

then return to Referral source (copy to client, as appropriate)

| | |PPSN:           |

|Client Name:       |DOB:    /    /      | |

|Referral Source |Name / Title: |      |

| |PCT / Specialist Service / OOH Co-op / Hospital Dept: |      |

|Preferred method of contact: |Telephone |      | Fax |      | |

| | Email |      | |

| |

|Referral Recipient |Name / Title : |      |

| |PCT / Specialist service / OOH Co-op |      |

| |

Please be advised that the attached referral has been received and (Please tick appropriate box)

| |    /    /      | |

|The referral is accepted Estimated date of client assessment: | | |

| | |

|Or | |

| The referral is not proceeding for the following reasons: |

| Consent not completed in referral form | Inadequate information provided in referral | Inappropriate Referral | Client declined service |

| |form | | |

| Client ineligible for services | Waiting list time inappropriate for client | Other: | |

|Comments and any further actions undertaken: |

|      |

| |      |Job Title |      |Date: |   /    /      |

|Name | | | | | |

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