Referral to Community Based Rehabilitation Service

Alliance Rehabilitation provides intensive, time based rehabilitation in the community. Rehabilitation programs are delivered by an experienced interdisciplinary team including physiotherapy, occupational therapy, exercise physiology, speech pathology, dietetics, diabetes education, psychology, neuropsychology and social work.

Centre based programs are offered across the Townsville Region including weekly outreach to Ayr, Charters Towers, Ingham (Cardwell), Magnetic Island and Palm Island and fortnightly to Richmond and Hughenden.

Referrals to the CBRS will be managed by Townsville Hospital and Health Service and triaged through a central referral hub. Please send referrals to: Email: TSV-Medicine-Referrals@health.qld.gov.au                Fax: (07) 4433 2501
	
Common Indications for Referral
•	General Rehabilitation
Intensive outpatient and home-based therapy for recovery after a health event or following significant de-conditioning  
•	Post-surgical rehabilitation
(Rehab after Surgery e.g. knee replacements)
Cognition, assistance with ADL’s, linking with community services, malnutrition prevention 
•	Occupational Therapy Driving Assessment
Assessment of a participant’s suitability and fitness to drive and facilitation of return to driving after illness or trauma
•	Stroke rehabilitation 
Intensive rehabilitation post stroke aimed at maximising long term outcomes
•	Cardiac rehabilitation (Palm Island)
Provides participants with knowledge and self-management skills following a cardiac event 
•	Chronic neurological rehabilitation 
Individualised programs for people with chronic and progressive conditions e.g. Parkinson’s disease, MND, MS
•	Mobility 
Activities to facilitate people’s community access and mobility e.g. wheelchair prescription
•	Hydrotherapy 
Gentle aquatic therapy programs focussed on regaining physical fitness and well-being and mobility
•	Bariatric weight management and mobility
MDT approach to weight management and mobility for community access, social inclusion and long-term outcomes
•	Frail elderly program
Falls Prevention, Swallowing and Malnutrition risk, Mobility and home safety
•	Smoking cessation  
Quitskills Brief Intervention program for tackling indigenous smoking	
 URN: 
Family name: 
Given name(s): 
Date of birth:  
                                 
Sex:       M       F      

Medicare no: 
	Phone (home): 

Phone (mobile): 

Address: 

Discharge address and contact details if different to above: 

Emergency Contact/NOK:	
 Consent to referral: This referral has been discussed with the participant and/or their guardian, and they understand and agree with the referral being made.	Aboriginal/Torres Strait Islander Status: 
 N/A            Aboriginal         Torres Strait Islander 
 Both Aboriginal and Torres Strait Islander 	
Is this person involved with Office of Public Guardian    Yes             No	
Does this person require support for communication (eg. aphasia / interpreter)    Yes             No 	
Please mark any of the following that apply:   My Aged Care      DVA Gold      Insurance/Compensation     NDIS 	
Rehabilitation goals of referral: 
•	  
•	  
•	  
•	  
•		
Is this a driving assessment referral?   
    No > Continue to next section
    Yes > You must complete the separate ‘Referral for Driving Assessment’ in addition to this referral Attached?  Yes	
Presenting health condition: 

Has there been deterioration in function? (Explain)

	
Has there been a recent hospital admission? 
(Date/Reason/Length of stay)
	Have you /will you send referrals to services other than Alliance Rehabilitation? 
(Please list)

	Are there other services currently involved? 
Home care package 
Private Allied Health   
Community support i.e Kith and Kin  
Other : 	
Medical Clearance: What level of physical demand is the person medically safe to work towards? (To be completed by a medical practitioner)
 *RPE – Borg’s Rating of Perceived Exertion 0 – 10 scale.	
	Very low physical demand (e.g. working in sitting or lying, very light walking – *RPE ≤2)	
	Low physical demand (e.g. short walks or pushing, 3 x week – *RPE 3-4)	
	Moderate physical demand (e.g. Walk, wheel, swim or cycle leisurely, ≤1 hour, 3-5 X week – *RPE 5-6)	
	High physical demand (e.g. Walk, wheel, run/jog, swim, cycle briskly ≥ 1 hour, ≥ 5 X week – *RPE 7-8)	
Is the participant safe to participate in water based activities:         Yes  No	
Are there precautions / restrictions / limitations that need to be observed during the program?
If Yes, please detail:

Is the participant at a risk of falling?     Yes   No
	
Referrer Details: 
Name:
Discipline: 
Address: 
Phone: 
Fax: 
Signature:                                                                               Date: 	
Please attach Health/Discharge Summary, Relevant Pathology