Aged Care Referral

Client Name *

First Name

Last Name

Client DOB

MM

DD

YYYY

Funding Type

Home Care Package

Short Term Restorative Care

Commonwealth Home Support Program

Private

Risk Assessment

Is there safe vehicle access and parking?

Is there mobile phone coverage?

Can animals be restrained?

Is there any alcohol/drug use in the house including paraphernalia?

Is there a history of violence within the house?

Are there any weapons/dangerous objects in the house?

Is anyone in the house living with an infectious disease?

Are there any religious, gender, or cultural preferences that we should be aware of?

Is a translator or support worker required at the assessment?

Has the person displayed behaviours of concern?

Does the person have a history of incarceration?

Does the person have unmedicated mental illness?

Are there other safety concerns that we should be aware of and that you would like to discuss?