Please fill out the form below, or forward completed HACC Ongoing Needs Identification Profiles for referral to our respite care.

Respite Care***Mandatory field
Choose respite service Gordon Park Bardon Garden City Ipswich Toowoomba

Referring Agency

Name of referrer

Referral To

	Carer support group
	In-home respite
	Day centre respite service
	Overnight Respite Service

Client Name

Client Address

Client Medical Condition(s) & Medication(s)

Other Service(s) Attending

Pension Type and number/ DVA Card holder?

Comments

CLIENT FUNCTIONAL PROFILE

DISABILITY

	Walks unaided
	Walks with stick/frame
	Walks with 1 person assisting
	Walks with 2 people assisting
	Wheels self
	Wheeled by others
	Bedfast

Does he/she have a history of falling yes no

Comments

FUNCTIONAL PROFILE

	Independent	Needs Assistance	Dependant
Transferring to / from bed / chair / walking aid				Requires lifting device
Bathing / Showering
Dressing / undressing
Eating				NG / PEG Tube Feed
Toileting
Catheter / colostomy / stomas				Not applicable
Grooming-teeth, hair, nails, makeup/shaving				Not applicable

Comments

CONTINENCE: (Note: minor stress incontinence, dribbling or faecal staining should not be regarded as incontinence, but noted in the comments)

	NEVER	SOMETIMES	NIGHT ONLY	ALWAYS
Urine
Faeces

BEHAVIOUR: How often does the patient exhibit each of the following behaviours?

	NEVER	SOMETIMES	NIGHT ONLY	ALWAYS
Wandering
Sleep disturbance
Disruptive behaviour

ORIENTATION

HEARING / SIGHT / SPEECH / TEMPERATURE SENSATION