Client name: Client's date of birth: Reason for referral: Available government funding source NDIS plan Home care package DS/HACC Continuity of Care funding (+65) None Does the client prefer to use FFS for this referral? Yes No Preferred outcome (if known) e.g. assessment, new wheelchair, transfer docs: Checklist completed by: Relationship to client: Service, location and client address (e.g. Support at home - Fig Tree Pocket, 17 Rosella St, Fig Tree Pocket): Who to contact to set appointments (key contact name): Relationship of key contact to client: Key contact details - phone: Email: Presenting problems: Describe the concern/s around pressure management: Background information: Has the person had a pressure injury or ulcer in the past: Does the person have a pressure relieving cushion and/or mattress: It is mandatory to make a referral when A) any items from 1-3 are present or B) 3 or more checklist items in total are present. Please selectI accept 1. Discolouration of skin (Stage 1) Please selectNoYes 2. Pressure ulcer (Stage 2, 3, or 4) Please selectNoYes 3. Skin tear Please selectNoYes 4. Incontinent (urine and/or faeces) Please selectNoYes 5. Skin is persistently moist (e.g. due to perspiration, continence, stoma) Please selectNoYes 6. Limited ability to reposition independently to relieve pressure Please selectNoYes 7. Are there concerns about malnutrition, recent weight loss or nutritional intake Please selectNo Yes 8. Presence of joint contractures and/or spasticity Please selectNoYes 9. Diabetic Please selectNoYes Presenting problems: Describe the concern/s around positioning: Completed sleep diary?: Does the person wake up and need assistance most nights? Please selectComfort/re positioningBreathing issuesPressure careUnsureOther Submit form Leave this field blank