Age Care Referral Home » Age Care Referral Aged Care Referral Form Referral Information Date of Referral: Referral Source: Self-ReferralFamily/CarerGP/Healthcare ProfessionalCommunity OrganisationOther Referrer's Details (if applicable): Has the client consented to this referral? YesNo (Consent must be obtained before proceeding) Client Details Full Name Preferred Name: Date of Birth: Age: Gender: MaleFemaleOther Contact Details: Address: Cultural and Identity Information Country of Birth: Are you of Aboriginal or Torres Strait Islander origin? AboriginalTorres Strait IslanderBothNo Preferred Language: Is an interpreter required? YesNo Care and Support Needs Reason for Referral : Services Required: Please SelectPersonal Care (e.g., dressing, showering)Domestic Assistance (e.g., cleaning, laundry)Community Access (e.g., transport, social outings)Health Management (e.g., medication support, allied health)Respite CareOther Does the client have a My Aged Care number? YesNo Does the client have any current care packages? YesNo Does the client require immediate care? YesNo Health and Wellbeing Health Conditions: (Please provide details, including chronic illnesses, disabilities, or mobility concerns) Medications: (List drugs and dosages) Has the client had any following check-ups in the past 12 months? Medical: YesNo Dental: YesNo Vision: YesNo Does the client have a mental health diagnosis? YesNo Current Living Situation Accommodation Type: Own HomeRentingLiving with FamilyAged Care FacilityOther Does the client live alone? YesNo Does the client pay rent or mortgage? YesNo How long has the client lived at their current address? Does the client feel safe in their home environment? YesNo Financial Information Primary Source of Income: Please SelectPensionSuperannuationSavingsOther Weekly Income (Approx.): Emergency and Family Contacts Does the client have any children? YesNo Additional Information Are there any legal concerns (e.g., power of attorney, guardianship)? YesNo Other relevant information:
