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: Hoist: Current transfer method and assistance required: - Select -YesNo Sit to stand: Current transfer method and assistance required: - Select -Independent1 person assist2 person assist Bed mobility: Current transfer method and assistance required: - Select -Independent1 person assist2 person assist This checklist needs to be filled out in consultation with someone who is familiar with the client’s transfer abilities. It is mandatory to make a referral to CPL physiotherapist/occupational therapist when: A) any items from 1-8 have been rated ‘Occasionally’ or ‘Often’, or B) 3 or more checklist items in total have been rated ‘Occasionally’ or ‘Often.’ - Select -I accept 1. Support care workers report injuries (or near misses) while transferring or re-positioning. - Select -NeverOccasionally Often 2. Support care workers report that transferring or repositioning a person is physically demanding. - Select -NeverOccasionally Often 3. Person size and weight significantly impacts his/her ability to assist with transfers or repositioning required. - Select -NeverOccasionally Often 4. Person’s ability to perform transfers is inconsistent, or their ability to complete transfers/follow directions is fluctuating during the day. - Select -NeverOccasionally Often 5. Person’s condition has changed due to recent surgery or functional deterioration that affects his/her ability to transfer or follow directions. - Select -NeverOccasionally Often 6. Altered tone/rigidity results in physically demanding transfers. - Select -NeverOccasionally Often 7. Person has skin integrity issues which are made worse by manual transfers/repositioning or the current sling or lift. - Select -NeverOccasionally Often 8. Person experiences an increase in pain level using current manual transfer or repositioning techniques. - Select -NeverOccasionally Often 9. There is limited working space to safely transfer or reposition the person. - None -NeverOccasionally Often 10. Current transfer (manual or hoist) and/or repositioning requires 2 support care workers or 1 support care worker and a family caregiver, who is not always able to assist. - None -NeverOccasionally Often 11. Incontinence issues result in frequent added transfers and/or bathing assist for scheduling. - None -NeverOccasionally Often 12. Person is increasingly resistive to care, or is displaying aggressive behaviour, during transfers or while being repositioned. - None -NeverOccasionally Often 13. Previous support care worker injury or reported physical demand has resulted in fewer workers willing to attend the client. - None -NeverOccasionally Often 14. Number of transfers per visit or per day and/or frequency of service is impacting support care worker safety and availability. - None -NeverOccasionally Often Comments: Submit form Leave this field blank