Wattletree Health Group New Client Referral
Client Details
First Name
*
Preferred Name
Client Last Name
*
Date Of Birth
*
Gender
*
Male
Female
Other
Phone Number
*
Street Address
*
Suburb
*
Postcode
*
Aged/Home Care Package?
Package Level
Care package details/level (if applicable)
Package details
Care package details/level (if applicable)
NDIS?
NDIS Number
Plan Manager
Does the client have an EPOA or MPOA?
Has the EPOA/MPOA been activated?
EPOA Details
EPOA / MPOA Upload
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Attach documents as necessary
Does the client have an Advanced Care Plan (ACP)?
Advanced Care Plan Details
Care Plan Upload
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Attach documents as necessary
Has the client's cognitive capacity been determined?
Result / Outcome
Capacity Assessment Upload
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Attach documents as necessary
Does the client have any recent OT/allied health assessments?
Assessments
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Attach documents as necessary
Alerts
*
Are there any current alerts regarding client behaviour, family dynamic, home access, parking, language, cultural, COVID etc. If none, please write 'none'
Client Contact Details (If Applicable)
Contact Name
Relationship to client
Contact Number
Client GP Details
GP Name
*
GP Contact Number
*
Referrer Details (making the referral)
Referring Organisation (If Applicable)
Referrer/Care Manager Name
*
Phone Number
*
Email
*
I have consent/authority from the client to make this referral and provide Wattletree Health Group with the participant's personal and medical details.
*
Relevant Medical Information/Client Background
*
Reason For Referral
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Pre-approval for emergency visits?
*
Yes
No
Wattletree Health Group offer a 24/7 emergency callout service for existing clients (3 hour minimum service charge at applicable rates). This is of particular benefit for clients with catheters or embedded foreign devices. If not approved, 24/7 number will be required for visit authorisation as necessary.
24/7 Approval Number
*
24/7 and After hours number to be called for emergency visit authorisation
Initial Service Request
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Attach documents as necessary
Approval for weekday evening (after 6pm) visits
Approval for weekend visits
Saturday visits
Sunday visits
Approval for emergency callouts (minimum 3 hour charge)
Callout conditions
WHG will source all supplies as necessary unless otherwise communicated in writing
Medical Summaries
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Attach relevant documents as necessary
How did you hear about us?
We are interested in how you heard about Wattletree Health Group (eg google, friend, GP, agency, newspaper, etc)
Quality/Referral | Version 3.3 | Last updated December 2023
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