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General Referral Form

This general information will allow our team to prepare for your appointment and ensure the relevant equipment is available.

Customer Details

Interpreter Required

Health Professional Details

Carer / Parent / Alternate Contact Details

Consent

Do you give consent to Indigo recording you information
Do you give consent to Indigo to liaise with Health Professional and / or Alternate Contact listed above?

If you answer no, this may prevent us from being able to assist you fully or provide you with the specialist services you are seeking from our organisation.

I understand that I can withdraw my consent at any time, however I understand that this could impact my service delivery.

Funding / Eligibility (select all that apply)

Please specify number

Required if Plan Managed

Required if Plan Managed

Funding / Eligibility Continued...
Home Care Package Level

Background Information

Summary of why the referral has been sent. What are the difficulties the person is having? What are their strengths / abilities? Include any relevant details relating to the person, their carers and environment

Please list any specific equipment items you wish to view. Please note, although we will endeavour to obtain these for the appointment, there is no guarantee of availability

What relevant equipment is the person currently using? Why is this not sufficient?

e.g. method of mobility and transfers, level of assistance required

e.g. difficulties with hearing, vision, speech, devices used, level of assistance required

e.g. can become agitated in new environments

e.g. height, weight, bariatric, petite

Declaration

Who would you like our Indigo representative to contact regarding the information provided in this form?
Did this individual fill in this form
Consent to act as liaison given by