Referral Form

Participant Details

Participant Name *

Participant preferred name *

Date of Birth *

Gender *

Participant Address *

Participant Email *

Phone *

Other (please state)

NDIS number

Aged Care Client Number

HCP Level

Referrer Details

Referrer Name *

Organisation *

Mobile *

Email address *

Office Phone

How did you hear about us? *

Word of mouthWebsiteInternetOther

Please specify

Reason(s) for appointment

Other Reasons not listed

Who is the best contact for the appointment with Think Continence? *

Phone contact:

Best Contact email

Location of Appointment

Visiting Preference *

In the clinic at Woree, CairnsHome BasedTelehealthOther

Medical/Disability Conditions

Other:

Payment Details

Payment details *

Invoice to Participant/CarerInvoice to Financial - Plan ManagerAgreed Subcontractor with Think ContinencePrivately funded

Best Email Address for Invoicing *

Plan Manager Invoice - Name

Mobile Phone

NDIS Plan Dates

Appointment Screen

Will anyone else be present during the appoinment *

YesNoUnsure

Please list all attendees and relationship to the participant: (include contacts) *

Are there any access issues to the location or animals present? *

Confidentiality & Consent

Confidentiality and Privacy

Your contact with Think Continence Specialist Cairns is confidential and private.

This means we will not disclose the information you provide to us to third parties unless you consent for us to do so. It is important to note that there are limits to confidentiality in exceptional circumstances including when there is a risk to you or others, or if we are responding to a subpoena or warrant. Your Registered Nurse will discuss this with you during your first appointment and answer any questions you might have.

You can find full information about our approach to confidentiality, and the limits to this in our Privacy Policy.

Health Record Management

We will create and keep Health Record for you which will record all relevant information relating to the treatment provided to you. We may also collect and store health information about you from third parties such as your doctor. Your health records are managed and protected in accordance with the applicable state and federal laws. Health records are legally required to be stored for several years following the conclusion of your treatment with us. The details of this can be found in our Privacy Policy. You are also able to request access to a copy of your Health Record. Please discuss this with your Clinical Nurse Consultant should you wish to do this at any time.

Limitation to Services

Think Continence is a wound, continence provider. Treatment is provided via prearranged, scheduled appointments. Clinical Nurse Consultants have limited availability for contact outside of schedule appointments. Clinical Nurse Consultants may not have an opportunity to respond to between session contact prior to your next appointment so this should not be relied upon for emergency matters.

For emergency matters please contact the appropriate agencies using the details:

Emergency Contacts

Think Continence is not an emergency service.

We are not able to respond to urgent or emergency matters and our communication channels (Phone, SMS, Fax, Email) are not monitored outside of standard business hours.

For urgent concerns relating the mental health or other emergencies please contact the appropriate emergency services:

Police, Fire, Ambulance (Emergency): 000 OR 1300 HEALTH for medical advice: 1300 432 584

Nature of Services

All practitioners are fully qualified registered nurses. We use a combination of evidenced based therapy (Wound, Continence and Stomal Therapy). Prior to commencing treatment your practitioner will discuss their proposed treatment approach with you and ensure you understand the rationale for the approach, including any identified risks.

Sensitive Area Consent for Continence Skin Assessment

I, have requested assessment by this Registered Nurse at Think Continence

As part of my therapeutic Continence and Skin assessment face to face,

and/or to insert a medical device such as a catheter, I am aware that the above-named RN will touch

or view the following area(s) of my body: (Please check buttons below)

During the assessment the Registered Nurse will verbally confirm with me that I have fully understood the proposed assessment including:

The nature of the assessment, including the clinical reason (s) for assessment of the above area(s) and the draping methods to be used
The expected benefits of the skin assessment
Insertion of the medical device
The potential risks of the skin assessment or insertion of the medical device
That consent is voluntary.
That I can withdraw or alter my consent at any time

Is the appointment for you or your child? *

MyselfMy childOther

Other: Name of person signing

Please confirm you have read and agree to terms in our Nursing Practice Privacy and Consent Form *

Signature for Consent *

Draw signature|Type signatureClear

I consent to my information being provided to Think Continence Pty Ltd for the purposes of referral, service delivery and inclusion in de-identified data reporting.

Insertion of Medical Device:

Do you have a letter from your GP for Catheter insertion?You need a referral from your GP to insert a medical device by our competent Registered Nurses. Not providing a letter of permission from your GP means the procedure cannot be undertaken.

You may upload your letter here.

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Message or Comment

Physical Function: (Mobility, Dexterity, Weight)

Are there any physical changes this includes recent weightloss/falls/injuries/wounds *

YesNo

Details

Communication: Hearing, Speaking, Language, Understanding

Are there any communication challenges *

YesNo

Details

Behaviours of Concern

Is there any history of behaviours of concern *

YesNo

Please note, our staff are not able to implement any restrictive practices

If yes, please provide recommended procedure for communicating with the participant.

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Do you require an NDIS Report? If so, when is it needed by?

Please provide recommended procedure for communicating with the participant

Does the participant have a restrictive practices plan *

YesNo

Provide any Medical reports including medical history *

YesNo

Please provide a copy of Medical record Confirming Medical Conditions by attaching here

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Provide any Allied Health Reports including Functional capacity *

YesNoClient has none done

Allied Health report attaching here

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NDIS Goals by attaching NDIS plan here, PDF or Word Doc only *

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Participant Details

Referrer Details

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