Transition Care Program

Thank you for completing this referral for a Transition Care Residential or Transition Care Domiciliary Bed.

Once received the Transition Care Coordinator will be notified of your referral via email and you will be contacted with time frames for bed availability. All mandatory fields must be completed for the referral to be generated.

Should you have any questions about the progress of your referral, please email admintcprcp@barwonhealth.org.au as our preferred method of contact.

Please fax the signed TCP consent form to 4215 3485

Date form completed:*

Are you requesting a residential or home based bed? Residential Home Based

Name of referring facility:*

Name of referring Clinician:*

Email of referring Clinician*

Position held:*

Name of referring medical consultant:

Current ward number:

Current ward telephone number:*

Next of kin contact details (must be able to be contacted during business hours).

Name:*

Email:

Home phone:*

Mobile:*

Surname of patient:*

Given name/s:*

Patient UR/Record Number:

Date of birth:*

Age:

Weight:*

Gender:

Is the patient Aboriginal or of Torres Strait Islander descent? Yes No

What is the patients first language?*

Is an interpreter required? Yes No

Address:

City/Suburb:

Marital Status:

Patient preferred telephone:

Religion:

Date of first hospital admission in this episode of care:*

Date of ACAS delegation for TCP:*

Admission diagnosis/current presenting problem/surgery date/relevant investigations:*

Consent discussed and signed including program fees:

Payment for pharmaceuticals and invoicing process from TCP pharmacy supplier discussed

Past medical history:*

Lives with:*

Other:

Special Equipment

Is special equipment required for the patient? Yes No

What is the equipment required?

Premorbid cognition

Please comment on the patient's premorbid cognitive function:*

Has referral been consented by patient/representative?:* Yes No

Payment Responsibilty

Select:

Other:

Payment Type Number:

TCP consent completed and signed?* Yes No

Signed by?

Verification

Thank You

The Transition Care referral has been lodged, you will be contacted by the Transition Care team shortly.