Complex Care Service - Referral Form

Referrals to the Complex Care Service can be made by the person’s general practitioner (GP), health professional, service provider or the person’s family / primary carer.

If the referral is accepted, it is on the basis that the persons GP will retain ongoing medical care for the person, will implement recommendations and follow through with care.

Client Details

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

MaleFemaleNon-binaryDo not wish to discloseOther

If other, please specify:

Street Address *

City *

State *

Postcode *

Phone Number *

Email Address

Does the person identify as: *

AboriginalTorres Strait IslanderAboriginal & Torres Strait IslanderNeither

Other Cultural Background:

Is an interpreter required?

YesNo

If yes, please specify:

Client Representative Details (if applicable)

First Name

Last Name

Relationship

Will the client representative provide consent for the referral?:

YesNo Unknown

Address

Phone Number

General Practitioner

Name *

Provider Number

Address *

Phone Number *

Reason For Referral

Reason For Referral/Relevant Medical Information *

Medical Conditions *

Past Medical History *

Is the person's intellectual disability? *

MildModerateSevereProfoundUnknown

Has the person had a Comprehensive Health Assessment completed by their GP in the past 12 months? *

YesNo Unknown

Has the person accessed any intellectual disability health service in the past, including their local Intellectual Disability Health Service? *

Yes NoUnknown

If yes, please provide details on service/s accessed:

Are there any concerns regarding the person's mental health or behaviours of concern *

Yes No

If yes, please specify:

Person Making the Referral

First Name *

Last Name *

Agency

Role

Phone Number *

Email *

I have obtained consent from the client or the client's representative to make this referral and provide the Complex Care Service with the client's personal and medical details. *

Please wait, files are uploading..

Complex Care Service | 18A Margaret Street, Strathfield NSW 2135

Phone: 0434 121 767 | Email: ccs@cds.org.au | Website: www.cds.org.au