PCCC REFERRAL FORM Please ensure all sections complete & consent received from Client or Parent / Guardian Client Name Address
DOB Day
Gender Tel/Mobile #
Month
Male
Year
Female
Consent to receive Text messages?
No
GP Name (or stamp)
Parent/Guardian/ NOK Relationship to client
Address
Tel / Mobile #
Tel #
Public patient card type: Referral from Acute Services
Yes
Card # Private Insurance
If facilitating hospital discharge, date of discharge
/
Yes /
No Provider Hospital Medical Record #
Referral To
Tick box for discipline(s) you are referring to Health & Social Care Professionals (PCT / HSCN)
GP Practice Nurse PHN RGN OT Physio SLT Social Work Home Help
Area Medical Officer Audiology Carers Service Chiropody/Podiatry CMHN / CPN Counselling CWO Diabetic Nurse Specialist
Specialist Teams / Services
Dental Services Dietitian Ophthalmology Psychology Other Refer to Directory of
Asylum Seekers Service Child & Family Services Disability Services Early Intervention Team Health Promotion Homeless Services
Services to specify:
Mental Health Services Older Persons Services Palliative Care Population Health Substance Misuse Other Refer to Directory of Services to specify:
Reason for Referral Please be specific
Relevant History/ Issues of Concern
Medications
Social Circumstances Live alone?
Yes
No
Interpreter required? Independent Mobility Other professionals involved in client’s care?
Yes
No With Aid Yes
With whom? Language Wheelchair No Don’t know
Immobile 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 Signature Preferred method of contact: Telephone PCT / HSCN / OOH Co-op / Hospital Dept
Date Tel #
Referred By
primary care referral form.doc
Fax
/
/
Email
PCCC Development Office, Carlow/Kilkenny LHO
DOB:
Client Name:
/
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
School attending
Class
Audiology – Hearing Test Date tested
/
1)
/
LEFT
/
2)
Pass
REFER
RIGHT
Pass
/
LEFT
REFER
Pass
REFER
RIGHT
Pass
REFER
Area Medical Officer / Nursing Vision Height / weight
Hearing Nutrition
Behaviour Developmental Delay
Parental Concern 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 Allowances / grants Carer Support
Dietetics Height
Community Links Finances Home repairs / refurbishment
Independent Living Information service Med Card application/review
Other state services/schemes Social Needs Other:
Attach full biochemistry report if available including: Na, K, Urea, Creat & Urinary Albumin. Please note fasting or non-fasting Weight BMI Glucose mmol/l Cholesterol mmol/l
HDL / LDL mmol/l
/
TG mmol/l
HbA1C%
Hb g/dl
Ferritin ng/l
Nursing Continence problem Chronic Illness Management Health Education / Promotion Existing Pressure Sore
Home Supports Leg ulcer / pressure care / wound care Nursing assessment
Yes
No
Stage
Has the client had a recent fall or at risk of falls? Barthel Score / 20 Assessments:
1
Yes
2
3
Preventive / Anticipatory Care Psychological Support Other: Waterlow Score
4
No MMSE Score
/ 30
EPDS Score
/ 30
Ophthalmology 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? Is the problem getting
1-2 Weeks
Better
Worse
2-4 Weeks
1-3 Months
3-6 Months
Unchanged
6+ Months
Night pain:
Is the client experiencing functional limitations with condition? eg activities of daily living, off work, etc. Difficulty with transfers
Bed
Difficulty with activity
Feeding
Equipment Breakdown
Yes
Chair Dressing No
Toilet
Shower
Bathing
Other
Bath
Yes
No
Yes
No
Other
If Yes, explain
Psychology (Child, Adult & Disability) Emotional Concerns Physical & Chronic Illness School Concerns
Fully detail psychological concern(s) you identify below in the Relevant History Section Behavioural Concerns Cognitive Impairment Abuse (Type): Relationships / Family Disability Act (AON) Risk: Psycho-social Concerns Other
Speech & Language Therapy Communication Issue: Recent Feeding, Eating, Drinking or Swallowing (FEDS) issue: Recent Involves: Understanding Speech AAC (augmentative/alternative communication)
Voice Other:
Reoccurrence Developmental Reoccurrence Developmental Expressive language
Retain a copy of this form for record keeping & audit purposes primary care referral form.doc
PCCC Development Office, Carlow/Kilkenny LHO
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)
DOB:
Client Name:
Referral Source
/
/
Name / Title: PCT / Specialist Service / OOH Co-op / Hospital Dept:
Preferred method of contact:
Fax
Telephone 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 Client ineligible for services
Inadequate information provided in referral form Waiting list time inappropriate for client
Inappropriate Referral
Client declined service
Other:
Comments and any further actions undertaken:
Name
primary care referral form.doc
Job Title
Date:
/
/
PCCC Development Office, Carlow/Kilkenny LHO
