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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