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	<TodaysDate>	
Referrer name	 <DrName>	
Provider number	<DrProviderNo>	
Practice name	<Practice>	
Practice address	<UsrAddress>	
Practice telephone	<UsrPhone>	
Practice fax	<UsrFax>	
Email	<PracEmail>	
PATIENT DETAILS
Name	<PtFullName>	
Address	<PtAddress>	
Residence type	<Residence Type - Private dwelling> Private Dwelling
<Residence Type - Supported accommodation> Supported accommodation 
Agency Details: <Supported Accomodation - Agency details>
<Residence Type - Other> Other <Residence type: Other>	
Phone	Home: <PtPhoneH> 
Mobile: <PtPhoneMob>	
Date of birth	<PtDoB>	
Gender		<Gender - Male> Male <Gender - Female> Female <Gender - Prefer not to say> Prefer not to say <Gender - Other> <Gender - Other>	
Aboriginal and/or Torres Strait Islander	<Aboriginal and/or Torres Strait Islander - Yes> Yes <Aboriginal and/or Torres Strait Islander - No> No <Aboriginal and/or Torres Strait Islander - Unknown> Unknown <Aboriginal and/or Torres Strait Islander - Prefer not to say> Prefer not to say	
DVA / Medicare no.	DVA: <PtDVANo>
Medicare No: <PtMCNo>	
Medicare expiry date	<PtMCExpiry>	
Interpreter required	<Interpreter Required - Yes> Yes <Interpreter Required - No> No
<Interpreter Required - Details>	
Key Contact	Name:<NOKName> 
Relationship to Patient: <NOKRelation> 
Phone: <NOKContact>
Email: 	
Patient consent 	<Patient Consent - Self-consenting> Self-consenting <Patient Consent - Legal Guardian> Legal Guardian <Patient Consent - OPA> OPA
Name of Consenting Person: <Name of Consenting Person> 
Phone of Consenting Person: <Phone number 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
	<Reason for referral (select one or more as appropriate) - Establish diagnosis> Establish diagnosis
<Reason for referral (select one or more as appropriate) - Advice> Advice
<Reason for referral (select one or more as appropriate) - Assessment and management plan> Assessment and management plan
<Reason for referral (select one or more as appropriate) - Reassurance for patient and/or family> Reassurance for patient and/or family
<Reason for referral (select one or more as appropriate) - Second opinion> Second opinion
<Reason for referral (select one or more as appropriate) - Other> Other, please specify: <If other, please specify>	
Eligibility criteria 
Select one or more as appropriate
	<Eligibility criteria (select one or more as appropriate) - Intellectual disability> Intellectual disability
<Eligibility criteria (select one or more as appropriate) - Significant developmental disability> Significant developmental disability
and
<Eligibility criteria (select one or more as appropriate) - Autism spectrum disorder> Autism spectrum disorder
<Eligibility criteria (select one or more as appropriate) - Mental illness or suspected mental illness> Mental illness or suspected mental illness
<Eligibility criteria (select one or more as appropriate) - Severe or profound communication and/or behavioural issues> Severe or profound communication and/or behavioural issues
<Eligibility criteria (select one or more as appropriate) - Other co-morbidities> Other co-morbidities
<Eligibility criteria (select one or more as appropriate) - Other complexities or issues which have not been able to be managed in mainstream services> Other complexities or issues which have not been able to be managed in mainstream services	
Relevant clinical history and/or examinations	<Relevant clinical history and/or examinations>
<SelectedPMH>	
Current medications	<CurrentRx>
	
Results of recent investigations	<Ix>
	
Allergies	<Reactions>
	
Relevant social history	<SocialHx>
	
Other considerations and patient requirements (e.g. visually impaired, literacy level)	<Other considerations and patient requirements (e.g. visually impaired, literacy level)>	
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