OCCUPATIONAL THERAPY 
DRIVING ASSESSMENT REFERRAL
	
Community Based Rehabilitation Service (CBRS) Driving Assessment referrals are managed by Townsville Hospital and Health Service and triaged through the central referral hub based at TTH. 
Please send referrals to:  Email: TSV-Medicine-Referrals@health.qld.gov.au  Fax: (07) 4433 2501.

N.B Referral form to Community Based Services is required for collection of demographic data and to identify if rehab episode is required concurrent to driving referral. Please ensure the Alliance Rehabilitation CBRS referral is attached. 
	
PARTICIPANT DETAILS
Participant Name: 
Date of birth:  
	COMMUNICATION
Difficulties:  Y   N     Receptive/Expressive       
Interpreter required:   Y   N     
Language spoken at home:
	
DRIVING ASSESSMENT RISK SCREENING 
To assist us in managing the referral, please complete the following checklist: If multiple factors are identified, please contact Alliance Rehabilitation Driver Assessment Occupational Therapist BEFORE completing this referral.
•	Co morbidity of the following diagnoses as per evidence/Austroads Fitness to Drive Guidelines (2016):
		  Dementia >24 months	                  Post intracranial surgery
		  Parkinson’s disease	                  Significant acquired brain injury
		  Epilepsy			  Multiple sclerosis
		  NIDDM or IDDM		  Cardiac arrest with chance of recurrence or 
		  Recent stroke or TIA	                      other heart condition 
•	Attention deficits or Autism spectrum disorder (please circle)
•	Any history of syncope / blackouts
•	Significant mental health conditions impacting cognition, concentration, attention
•	Use of Benzodiazepines or Tricyclic antidepressants
Please attach list of current medications	
LICENCE DETAILS
Driving History: Please note to proceed with assessment the client must hold a valid licence or learner’s permit. 
Drivers Licence: Type: 
Licence No: 
Expiry Date: 
Current Vehicle(s) Driven: 
Assessment Vehicle Requirements:  Manual/Automatic 
Please encourage participant to be assessed in the vehicle they usually drive and not related to category. 	LICENCE CONDITIONS 
Current Licence Conditions: 
 A (auto only) 
 S (spectacles to be worn)  
 V (vehicle modifications)  
 M (medical condition)
If yes, current medical certificate expiry date: 
 Other:
	
BEHAVIOUR
Are there any concerns regarding the client’s ability to control anger/emotions?   Y   N     
Attitude toward assessment: Understanding / Compliant / Resistant / Hostile	
MEDICAL HISTORY
Diagnosis/Date of Onset: 	

	
PHYSICAL 
Impaired / not impaired 

Modifications likely:  Y   N     
Details if known:
	
•		

	VISION
Impaired / not impaired 

Assessment required  Y   N     

 Participant informed computerised perimetry assessment / visual acuity and visual field testing by ophthalmology is required for all Occ. Therapy Driving Assessments. 	COGNITION 
Impaired / not impaired

Please see below for further information.
	
COGNITIVE SCREENING / NEUROPSYCHOLOGY ASSESSMENT 

 Occupational Therapy cognitive screening required and adequate for on road assessment to proceed. (If concerns are identified this will be escalated to referring Dr or Neuropsychologist for further consideration prior to proceeding). 

OR//

  Neuropsychology Assessment required PRIOR to proceeding with on road assessment.  Please include details of neuropsychology assessment bookings: NEUROPSYCH Ax to be booked at TTH // or // AR to arrange NEUROPSYCH. 
Additional details:
	
URGENCY OF REFERRAL

•	Urgent- public safety risk 
•	Requires appointment according to regular system of availability/ waiting list	

Please indicate below what advice you have provided to your client regarding their driving status whilst awaiting assessment:

 Must not drive whilst awaiting OT driving assessment
 May continue to drive whilst awaiting OT driving assessment
 May drive with conditions (list) whilst awaiting OTDA: Please list:
	
MEDICAL CERTIFICATION TO PARTICIPATE IN ON ROAD ASSESSMENT

Has the participant’s most recent driver licence been cancelled, or downgraded on medical grounds, or have you advised the participant notice proposing the cancellation, or downgrade of their driver licence on medical grounds?  Y   N     

IF YES  The Qld Gov Medical Certificate for Motor Vehicle Driver (Form 3712) is required: If participant has been informed not to drive/ or licence suspension for medical reasons has been enacted, this form must be completed with licence conditions to include “for occupational therapy driving assessment and rehabilitation purposes only” please include any other relevant conditions or information as appropriate.

The form can be located here: https://www.support.transport.qld.gov.au/qt/formsdat.nsf/forms/QF3712/$file/F3712_CFD.pdf
	
Referrer Details: 
Name:                                                                                                      Provider number:
                                                                                                                  Signature:
Hospital/ Clinic / Centre:
Phone: 
Fax:
Austroads Fitness to Drive Guidelines were considered/consulted when making this referral  Y   N     	
Please attach discharge summary or relevant medical reports including current medication lists.