Professional Referral

01 · Client information

Full name

Date of birth

Residential address

Phone number

Email address

Medicare number (optional)Only provide if authorised and useful for the application; otherwise leave blank.

Position number (optional)

Preferred language / dialect

Interpreter needed

02 · Family contact

Provide a child, family member or another person who can assist the client.

Name

Relationship to client

Phone number

Email address

Preferred contact

03 · Medical conditions

Describe the main or urgent conditions and their effect on safety, mobility, independence and daily activities.

Medical information

Other medical conditions

04 · Daily living and functional needs

Other needs

Additional information

05 · Aged care pathway and support status

Transition Care Program (TCP)

Carer Gateway / carer support

Commonwealth Home Support Program (CHSP)

Restorative Care Pathway (RCP)

RCP suitability and access are subject to assessment and eligibility. It does not replace safe hospital discharge planning or TCP assessment.

Additional pathway information

Selections indicate areas for review, not confirmed eligibility, classification or funding approval.

06 · Other important information and discharge planning

For example, hospitalisation, surgery, falls, significant changes in health, or assessments and reports being arranged.

Priority

Hospital / ward

Expected / actual discharge date

Other important information

07 · Referral information

Referring organisation

Referrer name

Role / profession

Contact number

Work email

Referral date

Reason for referral

08 · Client consent and signature

I consent to CareU using this information to assist with application support, assessment and relevant home care services, and communicating with relevant organisations where required.

If the client is not present, the professional may attest to consent already obtained and recorded. Do not draw a signature on the client’s behalf.

Consent record

Person providing consent

Name of person giving consent

Consent date

How consent was obtained

Client / authorised representative handwritten signature

I confirm the client or authorised representative has consented to the above use and necessary communication, including any uploaded health information.I am authorised to submit this referral, have recorded representative authority where applicable, and have explained that application assistance does not guarantee funding approval.

09 · Supporting documents (optional)

Upload an authorised discharge summary, assessment report, relevant clinical information or signed referral form. Include only information relevant to this referral.

Up to 3 files, 10 MB each, 15 MB combined: PDF, JPG, PNG or WebP.

Attachments are available only to authorised CareU staff.