Community Based Support Intake Form

If you require emergency respite 
please call Carer Gateway on 1800 422 737

About the carer
First name 	 <<Patient Demographics:First Name>>	
Last name	 <<Patient Demographics:Surname>>	
Preferred name 	 	
Date of birth 	 <<Patient Demographics:DOB>>	
Gender	 <<Patient Demographics:Gender>>	
Address 	<<Patient Demographics:Address>>	
Email		
Contact number 	 <<Patient Demographics:Phone (Mobile)>> 	
Employment status 	<<Employment status>>	
Carer status (e.g. primary carer/secondary carer/young carer)	     	
Relationship to person you care for	     	
Country of birth	 <<Patient Demographics:Country of Birth>>	
Language spoken at home 	 <<Patient Demographics:Language Spoken>>	
Disability, impairment or condition of the person you care for	     	
Indigenous status	 <<Patient Demographics:ATSI>>	
Alternative carer name	     	
Alternate carer phone number 	  <<Patient Demographics:Phone (Home)>>	

About the referrer 
Referrer’s name	  <<Doctor:Name>>	
Referrer’s contact number	  <<Doctor:Phone>>	
Referrer’s email	  <<Doctor:E-mail>>	
Does the referrer want to be 
contacted about the outcome	 Yes    No	
Background information about the referral	     	
Reason for referral	     	

Consents
Consent to share your de-identified information 
(i.e. no names shared) 	 Yes    No
  Date:  <<Miscellaneous:Date>>	
Carer has consent to act on behalf of the person they care for? (i.e. organise and set up services etc.)	 Yes    No
Date: <<Miscellaneous:Date>> 	
Consent to have personal information stored in Your Side database 	 Yes    No	
Consent to participate in follow-up research, surveys and evaluation 	 Yes    No	

About the care recipient
First name 	     	
Last name	     	
Preferred name 	     	
Type of funded plan/package (NDIS / My Aged Care) (if applicable) 	     	
Date of birth 	     	
Address 	Street:      
Suburb:      
State:          Postcode:      	
Contact details	     	
Disability/condition 	     	
Home Assessment completed	 Yes    No	
Details on Home Assessment 	     	
Discharge plan 	     	

Other comments
     	

Once you have filled out this referral form, please email it to: intake@yourside.org.au