REQUEST FOR OUTPATIENT APPOINTMENT
South Australian Intellectual Disability Health Service (SAIDHS)
Ingle Farm Recreation Centre
1/58 Beovich Rd
Ingle Farm 	5098
South Australia
Ph: 8257 7300
Fax: 8257 7399
Email: HealthSAIDHS@sa.gov.au 

Please note, SAIDHS is a consultation service model and unable to provide ongoing care, case management or emergency/crisis services.
REFERRER INFORMATION
Date of referral	<<Miscellaneous:Date>>	
Referrer name	<<Doctor:Name>>	
Provider number	<<Doctor:Provider Number>>	
Practice name	<<Practice/Location:Name>>	
Practice address	<<Doctor:Address>>	
Practice telephone	<<Doctor:Phone>>	
Practice fax	<<Doctor:Fax>>	
Email	<<Doctor:E-mail>>	
PATIENT DETAILS
Name	<<Patient Demographics:Full Name>>	
Address	<<Patient Demographics:Full Address>>	
Residence type	<<Residence type>>
<<Supported accommodation - Agency Details>>
<<If Other, please specify>>	
Phone	Home: <<Patient Demographics:Phone (Home)>> 
Mobile: <<Patient Demographics:Phone (Mobile)>>	
Date of birth	<<Patient Demographics:DOB>>	
Gender		<<Patient Demographics:Gender>>	
Aboriginal and/or Torres Strait Islander	<<Aboriginal and/or Torres Strait Islander  >>	
DVA / Medicare no.	DVA: <<Patient Demographics:DVA Number>> 
Medicare No: <<Patient Demographics:Medicare Number>>	
Medicare expiry date	<<Patient Demographics:Medicare Expiry Date>>	
Interpreter required	<<Interpreter Required>>
Details: <<Interpreter Required - Details >>	
Key Contact	<<Patient Demographics:Emergency Contact>><<Patient Demographics:Emergency Contact Relationship>><<Patient Demographics:Emergency Contact Address>><<Patient Demographics:Emergency Contact Phone>>	
Patient consent 	Self-consenting: <<Patient consent: Self-consenting >>
Legal Guardian: <<Patient consent: Legal Guardian>>
OPA: <<Patient consent: OPA>>
Name of Consenting Person: <<Patient consent: Name of Consenting Person>>
Phone number of Consenting Person: <<Patient consent: Phone No. of Consenting Person>>	
REFERRAL DETAILS
Presenting condition(s) or issue(s)		 <<Presenting condition(s) or issue(s)>>

Reason for referral 
Select one or more as appropriate
	Establish diagnosis: <<Referral Reason - Establish diagnosis >> 
Advice: <<Referral Reason - Advice>>
Assessment and management plan: <<Referral Reaso-Assessment and management plan >>
Reassurance for patient and/or family: <<Referral Rea-Reassurance for patient and/or family>>
Second opinion: <<Referral Reason - Second opinion >>
Other, please specify: <<Reason for Referral - Other>> <<Other, please specify >>	
Eligibility criteria 
Select one or more as appropriate
	Intellectual disability: <<Eligibility criteria - Intellectual disability >> 
Significant developmental disability: <<Eligibility criteria - Significant developmental disabilit>>
and 
Autism spectrum disorder: <<Eligibility criteria - Autism spectrum disorder >> 
Mental illness or suspected mental illness: <<Eligibility criteria - Mental illness or suspected mental>>
Severe or profound communication and/or behavioural issues: <<Eligibility criteria - communication and/or behaviour>>
Other co-morbidities: <<Eligibility criteria - Other co-morbidities>>
Other complexities or issues which have not been able to be managed in mainstream services: <<Eligibility criteria - Other complexities>>	
Relevant clinical history and/or examinations	<<Clinical Details:History List>>	
Current medications	<<Clinical Details:Medication List>>
	
Results of recent investigations	<<Summary:Investigation Results (Selected)>>	
Allergies	<<Clinical Details:Allergies/Adverse Reactions>>
	
Relevant social history	<<Clinical Details:Social History>>
	
Other considerations and patient requirements (e.g. visually impaired, literacy level)	<<Other considerations and patient requirements>>	
Relevant health professionals and contact details	<<Relevant health professionals and contact details>>

REGULAR GP INFORMATION (if not referrer)
Doctor name		
Practice name		
Practice address		
Practice telephone