Evolve Aged Care Referral

Evolve Aged Care Enquiry and Referral Form

If you have submitted an Enquiry that has been Accepted,

you have been directed back to this page to complete the Full Referral.

Date *

Enquiry

Enquirer Name *

Enquirer Phone

Enquirer Email *

Client: Preferred Name

Client: Suburb *

Client: Age *

Diagnosis of Client requiring Services *

Funding for the Client *

My Aged Care / Home Care PackagePrivate

Provider Company *

Contact *

Email *

Phone

Reason for Enquiry *

Assistive TechnologyHome ModificationsAged Care Assessment

Please describe the situation *

Please provide an ideal time frame *

Capacity to Enquiry (Directors)

This Client is suitable for Referral *

Yes - send referral back with "please complete"No - send polite declineNeeds liaising with Enquirer

Thank you - an apology for lack of capacity will be sent to the Enquirer

Thank you - this Referral form will be sent back to the Enquirer

Notes to ReferrerThese Notes will only be sent to the Enquirer if you select Yes or No for the Capacity Enquiry

Name of Enquirer

Liaise via Phone

Liaise via Email

Client Details

First Name *

Last Name *

Date of Birth *

Known As

Phone Number *

Email

Address *Include any specifics re parking or access

Suburb *

Reason for Referral *

Assistive TechnologyHome ModificationsAged Care Assessment

Client Representative

First Name

Last Name

Relationship to Client

Contact Phone Number

Contact Email

Referrer Details

First Name

Last Name

Organisation

Referrer's relationship to Client

Other relationship

Referrer Phone

Referrer Email *

The person being referred has given consent to this referral and consents to these details being kept on a cloud based client management system *

Funding Information

Funding Source *

My Aged Care / Home Care PackagePrivate

Invoicing Email *

Send Service Agreement to *

Contact for arranging appointments *

Any other reports or documents that may assist with Services for the Client

Browse

Risk Factors

Risk Decision *

Green (no known risks)Orange (some risks, please provide description)Red (requires comprehensive handover and 2 staff in attendance at any session, more details below)Blue (environment risk, please explain)

These risks may entail any persons present at the appointments or location, or involved in this Client's care

I will liaise with the Therapist to provide a support person for all visits for this Client *

Service Required

Select required service *

Occupational Therapy

Primary Diagnosis as recognised by Specialists *

Relevant Medical History *

Please provide any relevant documents or reports

Browse

Review by Directors

This Client is suitable for services *

YesNoNeed further info

Please describe what further info is required from referrer *

If no provide reasoning: *

This Client suitable to release Report before payment (e.g. known PM)

Suitable appointment location options *

HomeOther as needed by Client

Any further information

Staff Member Allocated *

Staff Member Email *

Ideal time frame for providing services *

Review by Therapist

I accept this referral: *

Yes NoRequires Further DiscussionAdmin Reset

Please do not select Admin Reset unless you are Admin

The Directors are happy for any Reports for this Client to be sent with payment after
(Known PM etc)

The Directors have asked for payment PRIOR to release of any Reports for this Client

If no, please provide reasoning: *

I am aware that the ideal time frame for providing services is:

Date/Time of proposed non-confirmed initial appointment *

Location of appointment

Liaise with Client for appointments

Liaise with Rep for appointments

Liaise with Referrer for appointments

Director Finalisation

Next Steps

Admin setup case file in SploseAdmin send SA

Change in Current Therapist?The SA will be setup with the Client's current Therapist, unless stated here to change and to whom

Ongoing Support hours or dollars for SA

Other hours or dollars for SA

Therapist Review

I accept this referral: *

Yes Requires Further Discussion

I am aware that the ideal time frame for providing services is:

Liaise with Client for appointments

Liaise with Rep for appointments

Liaise with Referrer for appointments

Director Finalise

Next Steps

Admin setup case file in SploseAdmin send SA

Further discussion is required, we will attend this with the Therapist - please await Service Agreement instructions

Ongoing Support hours or dollars for SA

Other hours or dollars for SA

Admin Actions

First Steps

Setup file in splose;Reason for Referral added to 'Other Details' during setup;Attached files uploaded (create a Referral Information folder if required) including Ref Form that comes through when completed;Any extra emails re this referral in admin@ added to Correspondence Folder (create if needed)

Therapist 1

Please add this appointment to Splose for Therapist 1

Report Tag selected

Ongoing Therapy Tag selected

Please await further instructions from the Directors directly in regards to the Services required for this Client

Please do not attend Case Plan setup

Case budget setup in Splose.
- Please title Surname dd.mm.yy - dd.mm.yy (date for a year from referral)
- Type: Budget
- Case Alert: 70% and 4 weeks out to Assigned Therapist
- for 1.5hours and note the full hours to be updated when SSA returned in Notes section of case

Second Steps

Client->Phone number added as Mobile number;Risk category tag added (if red or orange) and notes updated in Alerts;

Please choose required:

Private Service Agreement SnapForm click here

Please update "Person to liaise with for appointment" in Splose to:

SA sent

Sent Service Agreement for signing

Please add tag Unsigned SA in splose - include link to SA in Alerts

Send to Client

Send to Rep

Send to Referrer

Send to Therapist

Team member completing this Form *

Save and Complete Later