Referral Forms Do you know someone who would benefit from massage therapy ? We can’t wait to assist you and the person you support along their journey. Fill out our referral form today, quick and easy! REFERRAL FORM Home Care Provider/Coordinator Case Manager/Coordinator Email Address * Is the Cosumer Home Care Package Short Term Restorative Care Other STRC start date MM DD YYYY STRC end date MM DD YYYY PERSONAL INFORMATION * First Name Last Name Preferred name (if different from above) Date Of Birth * MM DD YYYY Gender Identity Male Female Other Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Does the client identify as any of the following diversity characteristics? Aboriginal and Torres Strait Islander Peoples People living with cognitive impairment, including dementia People who live in rural, remote or very remote areas People from Culturally and Linguistically Diverse (CALD) backgrounds Veterans People with a disability LGBTIQ+ people People with mental health problems and mental illness None of the above If yes above, please provide more information that would help us support this client in their home Country of Birth Preferred Language Emergency Contact * First Name Last Name Relationship * Phone * (###) ### #### Living Status Live Alone With Partner Other Are there any stairs into the clients home? Instructions for access? Are there any pets in the home? MEDICAL HISTORY Please indicate if any of the following are relevant to the clients medical history * Heart Issues (attacks, AF, angina) Neuropathy Arthritis Skin Issues Vertigo Current Infections (eg. Cellulitis) Aneurysm Stroke/TIA Cancer Pallative PTSD/Traumas Diabetes Fibromyalgia/CFS Dementia/Alzheimer's Multiple Sclerosis Non-verbal Parkinson's Disease Kidney Disease Vision Impairment High Blood Pressure Depression/Anxiety Low Blood Pressure Blood Clots/Blood Disorder Lymphoedema Hearing Impairment Respiratory Disease Autoimmune Disease Epilepsy Pacemaker Obesity Joint Replacement Other Medications eg. pain relief, blood thinners Please advise of any other injuries, illnesses, or surgeries relevant to the client's medical history. Treating Doctor Is the client under the care of an allied health professional? Does the client have a Advanced Care Directive? Yes No Use of mobility aids Wheelchair Walking Stick Crutches Wheeled Walker Mobility Scooter None Is there a risk of falls for this client? * Yes No Unsure Does the client have mobility issues that would restrict them from receiving treatment on a massage table? * Yes No Unsure Preferences for massage therapist * Male Female No Preference Recommended or desired frequency for massage therapy * Weekly Fortnightly Monthly Subject to massage therapist recommendation Preferred day/time for appointments * Morning Afternoon Monday Tuesday Wednesday Thursday Friday Saturday Sunday Anything else that would help us understand the client's care requirements? Thank you!
