REQUEST FOR 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 

SAIDHS provides comprehensive health assessment and planning for adults with moderate, severe, or profound intellectual disabilities and complex care needs to support ongoing care by mainstream health services.  SAIDHS does not provide emergency/crisis services, ongoing medical or psychiatric management, IQ assessments, case management or assessment/medication advice for Autism or ADHD in the absence of other referral criteria. For consumers with mild intellectual disabilities, SAIDHS can advise on where to access appropriate health services and can provide clinical advice and support to clinicians working within mainstream health services if required. 
REFERRER INFORMATION
Date of referral	<<Miscellaneous:Date (short)>>	
Referrer name & Provider number	<<Doctor:Name>>	
Provider number	<<Doctor:Provider Number>>	
Relationship to patient	<<Relationship to patient>>	
Practice name	<<Practice/Location:Name>>	
Practice address	<<Practice/Location:Address>>	
Practice telephone	<<Practice/Location:Phone>>	
Practice fax	<<Practice/Location:Fax>>	
Email	<<Practice/Location:E-mail>>	
Consent for referral 
(specify who has provided consent)	<<Consent for referral>>
Details of consent: <<Details of consent>>	
Patient consent	<<Patient consent>>
Name of consenting person:<<Patient Demographics:Full Name>>
Phone number of consenting person:<<Patient Demographics:Phone (Mobile)>>	
Doctor name		
Practice name		
Practice address		
Practice telephone		
Practice fax:		
Practice Email:		

ELIGIBILITY CRITERIA
Eligibility criteria 
Select one or more as appropriate
	 <<Eligibility criteria>>	

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

PATIENT DETAILS
Name	<<Patient Demographics:Full Name>>	
Address	<<Patient Demographics:Full Address>>	
Residence type	 <<Patient Residence Type>>
Accommodation details (agency name, phone, email): 
<<Accommodation details(agency name/phone/email)>>	
Patient Phone (if applicable)	<<Patient Demographics:Phone (Mobile)>>	
Date of birth	<<Patient Demographics:DOB>>	
Gender		<<Patient Demographics:Gender>>	

Aboriginal and/or Torres Strait Islander	<<Patient Demographics:ATSI>>
<<Patient Demographics:Ethnicity>>	
Interpreter required	<<Interpreter Required>>
Details: <<If interpreter required, details:>>	
Key Contact 	Name: <<Patient Demographics:Emergency Contact>>
Relationship to patient: <<Patient Demographics:Emergency Contact Relationship>>
Phone: <<Patient Demographics:Emergency Contact Phone>>
Email: <<Key Contact Email: >>	

REFERRAL DETAILS
Reason for referral 
(please describe relevant details e.g. 
•	need for SAIDHS input
•	any recent changes
•	barriers to management in mainstream services	<<Reason for referral>>

	
Relevant clinical history and/or examinations	<<Clinical Details:History List>>

	
Results of recent investigations
(Attach copies of results)	<<Summary:Investigation Results (Selected)>>

	
Current medications
(please list or attach current medication summary)	<<Clinical Details:Prescription List>>
<<Clinical Details:Medication List>>

Allergies	<<Clinical Details:Allergies/Adverse Reactions>>
	
Current Supports 
(what does the person need assistance with)	Life domains	
Level of assistance	

Mobility	
<<Level of assistance for Mobility>>

Personal Care	
<<Level of assistance for Personal Care>>

Communication	
<<Level of assistance for Communication>>

Travel	
<<Level of assistance for Travel>>	

Money Management	
<<Level of assistance for Money Management>>

	
Relevant health professionals and contact details	Other Medical Specialists involved: <<Other Medical Specialists involved:>>
Support Coordinator: <<Support Coordinator:>>
Behaviour Support Practitioner: <<Behaviour Support Practitioner:>>
Other Allied Health Professionals: <<Other Allied Health Professionals:>>