Referral Form

We Are Committed To Client Outcomes

Please complete and return to our Intake & Assessment Team via the submit button at the end of the form. One of the team will contact you within 24 hours to proceed with the next step.

Today's date:Today's date

Referrer information:

Please disregard if this is a non medical referral

Signature

Client information:

Date of Birth:

Have they previously attended Arrow Health?

YesNo

Have they been admitted to any hospital or AOD rehabilitation facility in the last 12 months?

YesNo

If yes, was it within the last 28 days?

YesNo

If yes, please name the facility/ies:

Do you plan to treat this person post discharge?
Please disregard if this is a non medical referral

YesNo

Are they on any medications?
Please specify the date, the name and dose of each medication the person currently takes

Suicide/self harm risk?

YesNo

Please provide details of suicide or self harm risk:

Aggression/violence risk?

YesNo

Please provide details of aggression or violence risk:

Mental health history?

YesNo

Please provide details of mental health history:

Mobility concerns?

YesNo

Please provide details of mobility concerns:

Medical conditions (including open wounds or pressure sores)?

YesNo

Please provide details of medical conditions: