OFFICE USE ONLYReceived: ___ / ___ / ____

Service ProviderReferral Form

1. Key contact personReferral is: Priority Routine

Risk issues: Yes No

Relationship to person with dementia/memory loss:      

Surname:       Given name:      

Date of birth:       ☐ Est Age:       Gender: ☐ M ☐ FAddress:      Suburb:       Postcode:       State:      Phone (H):       Phone (W):      Mobile:       Email:      Country of birth:      

Restrictions on contact/best times:      Language spoken at home:       Preferred language:       ☐ Interpreter required

☐ Aboriginal ☐ Torres Strait Islander ☐ Aboriginal and TSI ☐ Neither

☐ GLBTI ☐ Homeless or risk of homelessness ☐ Younger onset dementia ☐ None

Dementia Australia Vic Division now provides email and video conference counselling services. Clients can also self-refer at helpwithdementia.org.au

My Aged Care (if aged 65 years or older)Is the key contact person registered with My Aged Care? ☐ Yes ☐ NoIf YES (above), please include the relevant Aged Care Number:                

Does the key contact person consent to being referred to My Aged Care in order to receive DA services? ☐ Yes ☐ No

Client contributions associated with some servicesREAD TO CLIENT: There is a small contribution charged for some services, whilst other services are free of charge. The contribution is assessed on the basis of the pension status of clients involved in the service. If this contribution presents difficulty for you, you can provide your best details for someone to contact you. For more information see Appendix 1.

Pension Status☐ Full Pension ☐ Part Pension ☐ No Pension ☐ Level 3 or 4 Package Recipient

Contact detailsSurname:       Given name:      Phone (mobile/home):       Email:      

Income Type☐ Aged Pension ☐ Other government pension or benefit ☐ Veterans’ Affairs Pension (Gold)☐ Carer Payment ☐ Service Pension ☐ Veterans’ Affairs Pension (Other DVA Card)☐ Disability Support Pension ☐ Sickness Allowance ☐ Veterans’ Affairs Pension (White)☐ No Pension ☐ Sole Parent Pension ☐ Widow’s Pension☐ Not stated/inadequately described☐ Declined to answer

☐ Special Benefit☐ Unemployment-related benefits

DVA Card Status☐ No DVA card ☐ DVA Card Gold ☐ DVA Card White☐ Not stated/inadequately described ☐ DVA Card Orange ☐ DVA Card Other

Accommodation☐ Boarding house/private hotel ☐ Private residence – public rental ☐ Share supported accommodation

☐ Community housing ☐ Private residence – private rental ☐ Short-term crisis, emergency or transitional accommodation facility

☐ Domestic-scale supported living facility ☐ Private residence rented from Aboriginal comm. ☐ Supported accommodation facility☐ Group home ☐ Private residence – mobile home ☐ Supported residential care☐ Independent living within retirement village

☐ Psychiatric/mental health community care facility ☐ Temporary residence in Aboriginal comm.

2.2.5.a V10 Jan-18 Page 1 of 5

☐ Not stated/inadequately described ☐ Residential aged care: high level care ☐ Other☐ Private residence – owned/purchasing ☐ Residential aged care: low level care

Living Arrangements☐ Lives alone ☐ Lives in residential high care facility ☐ Other☐ Lives with family ☐ Lives in residential low care facility ☐ Homeless☐ Lives with spouse ☐ Lives in transitional care ☐ Not stated/inadequately described

2. Person with memory loss/dementia (if not key contact person)

Surname:       Given name:      

Date of birth:       ☐ Est Age:       Gender: ☐ M ☐ FAddress:      Suburb:       Postcode:       State:      Phone (H):       Phone (W):      Mobile:       Email:      Country of birth:      

Language spoken at home:       Preferred language:       ☐ Interpreter required

☐ Aboriginal ☐ Torres Strait Islander ☐ Aboriginal and TSI ☐ Neither

☐ GLBTI ☐ Homeless or risk of homelessness ☐ Younger onset dementia ☐ None

My Aged Care (if aged 65 years or older)Is the person with memory loss/dementia (if not key contact) registered with My Aged Care? ☐ Yes ☐ NoIf YES (above), please include the relevant Aged Care Number:                

Does the person consent to being referred to My Aged Care in order to receive DA services? ☐ Yes ☐ No

Dementia/memory loss detailsDementia type:       Date of diagnosis:      

Diagnosed by:       Role:       Is dementia

confirmed:      

Income Type☐ Aged Pension ☐ Other government pension or benefit ☐ Veterans’ Affairs Pension (Gold)

☐ Carer Payment ☐ Service Pension ☐ Veterans’ Affairs Pension (Other DVA Card)

☐ Disability Support Pension ☐ Sickness Allowance ☐ Veterans’ Affairs Pension (White)☐ No Pension ☐ Sole Parent Pension ☐ Widow’s Pension☐ Not stated/inadequately described☐ Declined to answer

☐ Special Benefit☐ Unemployment-related benefits

DVA Card Status☐ No DVA card ☐ DVA Card Gold ☐ DVA Card White☐ Not stated/inadequately described ☐ DVA Card Orange ☐ DVA Card Other

Accommodation☐ Boarding house/private hotel ☐ Private residence – public rental ☐ Share supported accommodation

☐ Community housing ☐ Private residence – private rental ☐ Short-term crisis, emergency or transitional accommodation facility

☐ Domestic-scale supported living facility ☐ Private residence rented from Aboriginal comm. ☐ Supported accommodation facility☐ Group home ☐ Private residence – mobile home ☐ Supported residential care

☐ Independent living within retirement village ☐ Psychiatric/mental health community care facility ☐ Temporary residence in Aboriginal comm.

☐ Not stated/inadequately described ☐ Residential aged care: high level care ☐ Other☐ Private residence – owned/purchasing ☐ Residential aged care: low level care

Page 2 of 5

Living Arrangements☐ Lives alone ☐ Lives in residential high care facility ☐ Other☐ Lives with family ☐ Lives in residential low care facility ☐ Homeless☐ Lives with spouse ☐ Lives in transitional care ☐ Not stated/inadequately described

Other key agencies/services involvedContact person/agency Address Phone                                                   

Issues requiring assistance☐ Changes in behaviour ☐ Coping and mental health ☐ General information ☐ Social isolation☐ Carer stress ☐ Dealing with diagnosis ☐ Memory Lane Café ☐ Support and care☐ Counselling ☐ Education ☐ Planning for the future ☐ Younger onset dementia☐ Online counselling ☐ Family and relationships ☐ Progression of the disease ☐ Other:      

Reason for Referral     

If risk has been identified, please detail nature of the risk and how it has been managed to date:     

Referred by

Name of worker:       Role:      

Organisation:      

Postal address:       Suburb:       Postcode:     

Phone:       Email:      

I would like a brief letter/email advising me whether the key contact person has accepted Dementia

Australia Vic Division services:

☐ Yes ☐ No

Consent

☐ I have discussed this referral with the key contact person, and they consent to being contacted by Dementia Australia Vic Division.

Name of referrer:       Signature of referrer:       Date:      

Return to: Gateway ServicesDementia Australia Vic DivisionLocked Bag 3001Hawthorn Vic 3122 Fax: (03) 9815 7801Email: Vic.gateway@dementia.org.au

To discuss this referral please contactGateway Services on (03) 9815 7800

Page 3 of 5

Page 4 of 5

APPENDIX 1: Client Contribution Schedule & Information

Client Contribution Information

Dementia Australia Vic Division regularly reviews funding guidelines set by our government funding bodies. Our government funding bodies have requirements requiring us to collect a contribution for some of our services. The schedule below provides information regarding current contributions.

Please be assured that no person will be denied access to a service because of financial hardship or inability to pay fees. If you experience difficulties or have circumstances which impact on your ability to pay the scheduled contribution (as below), please provide us contact details so Dementia Australia Vic Division staff can discuss with you.

Services requiring a contribution include SOME counselling & support services, Memory Lane Cafés and SOME Family Information and Support Sessions. All contributions collected are used by Dementia Australia Vic Division to provide more services to people impacted by dementia.

Dementia Australia Vic Division 2016/17 Client Contribution Schedule for CHSP & HACC funded servicesPension status

Service

Full-pension* Part-pension No pension Care package Level 3 or 4

(full cost recovery)

Individual – counselling,

information & support

(per session)

$5 $10 $30 $98.90

Couple/Family/Group –

counselling & support

(total per session)

$10 $20 $50 $98.90

Family Information &

Support Sessions (per

person per session)

$10 $15 $30 $50

Dementia Australia run

Memory Lane Cafés $5 $5 $5 $5 (Note: not full cost

recovery)

*Full pension includes Aged Pension, Disability Support Pension, Carer Payment, Health Care Card, NewStart allowance**Pension status will be assessed for clients involved in the service

Page 5 of 5