Referral Form - Care Finder

	

	

Checklist for referring to Care Finders 

This checklist is for determining whether or not to refer a person to Care Finders. If you are unsure, please contact COTA Tasmania on 1800 518 048 to check, before completing a referral. Please ensure that the client is willing to be referred to Care Finders and is happy to be contacted by a staff member.

The Care Finders service is for older people who need intensive support to access My Aged Care and other supports in the community, who could otherwise fall through the cracks. For more information,
 see: Help from a care finder | My Aged Care
    Person meets all of the below criteria 	   X if yes	
 Is the person in one of the following age groups:		
•	65 years and over, or	o	
•	50 years and older for an Aboriginal or Torres Straits Islander person, or	o	
•	50 years or older on low income and homeless or at risk of being homeless, or	o	
•	45 years or older for an Aboriginal or Torres Strait Islander people and on a low income and homeless or at risk of being homeless?	o	
•	Does the person require help (either with an aid or assistance from another person) with one or more tasks of daily living (e.g. walking, dressing, preparing meals, making decisions, eating, managing medication, managing with house work, transportation, social connections), 	o	
       or		
• Is the person frail or prematurely aged and experiencing housing stress/ not having secure accommodation?	o	
  Is the person without family, friends, carer or a representative they would be comfortable to receive       help from, who is willing and able to help them access aged care services?	o	
   Person meets one of the below criteria		
  Does the person experience communication barriers such as limited English language or literacy skills?	o	
  Does the person experience difficulty processing information to make decisions?	o	
 Could the person experience a crisis in their care situation (within the next year) but they are resistant   to engaging with aged care services?
 *Note: If the person’s safety is at immediate risk, connect them with appropriate emergency                    service(s).	o	
  Does the person have past experiences that mean they are hesitant to engage with aged care,                   institutions, or government?	o	

 REFERRAL FORM – REFERRER TO COMPLETE		
 Referrer’s details		
 Referrer’s name	 <UsrName>	
 Referrer’s organisation	 <Practice>	
 Preferred phone	  <UsrPhone>	
 Preferred email	 <PracEmail>	
 What is the best time to contact you?	 	
 How did you hear about our Care Finder 
 aged care navigation service?	  	
 Client details		
 Client’s name	 <PtFullName>	
 Date of birth	 <PtDoB>	
 Preferred phone number(s)	 <PtPhoneMob>  <PtPhoneH>	
 Residential address	 <PtAddress>	
 Email address	 <PtEmail>	
 Next of Kin / Carer / Support Person (if                applicable)	 <NOKName>	
 Nature of Relationship	 <NOKRelation>	
 Preferred phone number(s)	 <NOKContact>  <NOKContact2>	
 Email address	 	
 Does the client (or Next of Kin / Carer /
 Support  Person) need an interpreter?	  o	Yes		o	No	

  If Yes, please state language (including dialect, if applicable):	
 Are there any preferred days of the week or                times for contact?		
 What is the client seeking?	 o	General information about aged care	
    o 	Help navigating aged care	
 What are the main issues where the client           would like help or information? (Add an extra       page if needed)		

CONSENT TO EXCHANGE INFORMATION
If you want to receive updates about the progress of this referral, please complete the section below and ask the client for their signature. If this is not practicable, obtain verbal consent and provide confirmation that this has occurred.
 I consent to COTA Tasmania and <Practice> [insert referrer organisation and/or name] exchanging information about my / the client’s situation and service options. I am aware that my consent is valid for 12 months after this date, and I can withdraw my consent at any time, verbally or in writing.

Client signature:…………………………………………………………………………………

 Date: <TodaysDate>

OR

 Next of Kin / Carer / Support Person name:   <NOKName>

 Relationship to client: <NOKRelation>

 Signature:…………………………………………………………………………………

 Date: <TodaysDate>

OR

 Verbal consent provided by:    Client  o		Next of Kin/Carer   o

 Worker name & signature: ……………………………….………………………………………………………………………….
 Date: <TodaysDate>

Please email this form to carefinder@cotatas.org.au or post to:
Intake Officer
COTA Tasmania Care Finder service
Level 12, 39 Murray Street
Hobart TAS 7000

Personal Information Collection Statement 
At all times, we only collect the information that we need for the particular function or activity we are carrying out. The main way we collect personal information about you/the client is when it is given to us verbally or in writing by you/the client, or other relevant support agencies and organisations. This may include personal information such as contact details and support needs. Sometimes we may need to collect sensitive information to help us connect you/the client to relevant services and supports. This might include information about health, needs, circumstances or culture. We will obtain relevant consent and only disclose sensitive information for the purposes for which it was provided to us, unless otherwise required by law.