MRO SOCIAL WORK ENQUIRY FORM Name * Date * Email Address * Contact Number Is the enquiry for you or someone else, please specify: * Yes No Client's Name First Middle Last Contact Number Client's Date of Birth Claim Number (If applicable) Client's Address Suburb State Post Code TELEHEALTH Due to the COVID-19 situation we are requesting this section is completed at time of referral Does the client have internet service and a computer, tablet or smart phone: * — Select — Yes No Is the client happy to proceed with a video health conference (via phone or device): * — Select — Yes No Does the client have a support person who can hold the device: * — Select — Yes No Type of Injury / Illness * Reason for referral Income / finanical assistance (Centrelink, DVA, DSS etc) Information, support, guidance and counselling Aged Care Assessment Program (ACAP or ACAT) Carer support Housing and Nursing home placement COVID-19 support Crisis intervention / Emergency relief Other If other, please provide further details? SAFETY - Are there any known risks (including violence, aggression, drug / alcohol use or behaviour) which would place our MRO staff at risk conducting a home assessment? * Yes No If yes, please provide further details? SAFETY (COVID-19) - Has the client or anyone in the household had known exposure to COVID-19, is high risk or vulnerable (i.e. immunosuppressed or over 65 years), has travelled overseas 14 days prior to the assessment and / or is not feeling well, showing signs of fever, shortness of breath or flu-like symptoms? * Yes No If yes, please provide further details? When would you like the assessment completed? Urgent* 1-2 Weeks 2-4 Weeks Other (Please Specify) *If your enquiry is urgent please call the MRO Office on 0435 947 334 Additional Information
