Specialist Teams / Services - SICP

1 Primary care referral PCCC Development Office, Carlow/Kilkenny LHO PPCCCCCC RREEFFEERRRRAALL FFOORRMM Please ensure all sections complete & consent received from Client or Parent / Guardian Client Name Address DOB Day Month Year Gender Male Female Tel/Mobile # Consent to receive Text messages? Yes No Parent/Guardian/ NOK GP Name (or stamp) Relationship to client Address Tel / Mobile # Tel # Public patient card type: Card # referral from Acute Services Private Insurance Yes No Provider If facilitating hospital discharge, date of discharge / / Hospital Medical Record # referral To Tick box for discipline(s) you are referring to Health & Social care Professionals (PCT / HSCN) Specialist Teams / Services GP Practice Nurse PHN RGN OT Physio SLT Social Work Home Help Area Medical Officer Audiology Carers Service Chiropody/Podiatry CMHN / CPN Counselling CWO Diabetic Nurse Specialist Dental Services Dietitian Ophthalmology Psychology Other Refer to Directory of Services to specify.

2 Asylum Seekers Service Child & Family Services Disability Services Early Intervention team Health Promotion Homeless Services Mental Health Services Older Persons Services Palliative care Population Health Substance Misuse Other Refer to Directory of Services to specify: Reason for referral Please be specific Relevant History/ Issues of Concern Medications Social Circumstances Live alone? Interpreter required? Yes No Yes No With whom? Language Mobility Independent With Aid Wheelchair Immobile Other professionals involved in client s care ? Yes No Don t know If yes provide name & contact details HAS CLIENT (OR PARENT/GUARDIAN) CONSENTED TO THIS referral ? YES NO HAS CLIENT (OR PARENT/GUARDIAN) CONSENTED TO SHARING OF HIS/HER INFORMATION?

3 YES NO Referred By Name / Title Date / / Signature Tel # Preferred method of contact: Telephone Fax Email PCT / HSCN / OOH Co-op / Hospital Dept primary care referral PCCC Development Office, Carlow/Kilkenny LHO Client Name: DOB: / / Page 2 Essential Information for Discipline Referrals This is not an assessment form ; it is for the purpose of Interdisciplinary referral ONLY CHILD & ADOLESCENT REFERRALS All Referrals Public Health Nurse Report Available? Yes No School attending Class Audiology Hearing Test Date tested 1) / / 2) / / LEFT Pass REFER RIGHT Pass REFER LEFT Pass REFER RIGHT Pass REFER Area Medical Officer / Nursing Vision Hearing Behaviour Parental Concern Height / weight Nutrition Developmental Delay Child Welfare Other Social Work - In case of Emergency, contact should be made with An Garda Siochana Child Protection/Welfare Concerns Children in care Family Support Early Intervention Other care and Custody arrangements regarding child, if known.

4 ALL REFERRALS CWO / Social Work Detail family size & circumstances in Relevant History section Accommodation Allowances / grants Carer Support Community Links Finances Home repairs / refurbishment Independent Living Information service Med Card application/review Other state Services /schemes Social Needs Other: Dietetics Attach full biochemistry report if available including: Na, K, Urea, Creat & Urinary Albumin. Please note fasting or non-fasting Height Weight BMI Glucose mmol/l Cholesterol mmol/l HDL / LDL mmol/l / TG mmol/l HbA1C% Hb g/dl Ferritin ng/l Nursing Continence problem Chronic Illness Management Health Education / Promotion Home Supports Leg ulcer / pressure care / wound care Nursing assessment Preventive / Anticipatory care Psychological Support Other: Existing Pressure Sore Yes No Stage 1 2 3 4 Waterlow Score Has the client had a recent fall or at risk of falls?

5 Yes No Assessments: Barthel Score / 20 MMSE Score / 30 EPDS Score / 30 Ophthalmology Snellen Visual Acuity (at 20ft/6m) Distance VA {R} VA {L} Near VA {R} VA {L} Physiotherapy & Occupational Therapy Attach copies of X-rays, MRI, DEXA scans, etc if available How long has the client had complaint? 1-2 Weeks 2-4 Weeks 1-3 Months 3-6 Months 6+ Months Is the problem getting Better Worse Unchanged Night pain: Yes No Is the client experiencing functional limitations with condition? eg activities of daily living, off work, etc. Yes No Difficulty with transfers Bed Chair Toilet Shower Bath Other Difficulty with activity Feeding Dressing Bathing Other Equipment Breakdown Yes No If Yes, explain Psychology (Child, Adult & Disability) Fully detail psychological concern(s) you identify below in the Relevant History Section Emotional Concerns Behavioural Concerns Cognitive Impairment Abuse (Type): Physical & Chronic Illness Relationships / Family Disability Act (AON) Risk: School Concerns Psycho-social Concerns Other Speech & Language Therapy Communication Issue: Recent Reoccurrence Developmental Feeding, Eating, Drinking or Swallowing (FEDS) issue: Recent Reoccurrence Developmental Involves.

6 Understanding Speech Voice Expressive language AAC (augmentative/alternative communication) Other: Retain a copy of this form for record keeping & audit purposes primary care referral PCCC Development Office, Carlow/Kilkenny LHO PPCCCCCC RREEFFEERRRRAALL AACCKKNNOOWWLLEEDDGGEEMMEENNTT Please acknowledge that you received the referral by completing and signing below, then return to referral source (copy to client, as appropriate) referral Source Name / Title: PCT / Specialist Service / OOH Co-op / Hospital Dept: Preferred method of contact: Telephone Fax Email referral Recipient Name / Title : PCT / Specialist service / OOH Co-op Please be advised that the attached referral has been received and (Please tick appropriate box) The referral is accepted Estimated date of client assessment: / / Or The referral is not proceeding for the following reasons: Consent not completed in referral form Inadequate information provided in referral form Inappropriate referral Client declined service Client ineligible for Services Waiting list time inappropriate for client Other: Comments and any further actions undertaken: Name Job Title Date: / / Client Name: DOB: / /