SLHD Transition Aged Care Program (TACP Community) Referral Form

Referral date : 09-Jun-2026

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CONSENT FOR REFERRAL AND ASSESSMENT

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Referrer Details

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Patient Information

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Details For Assessment

Will anyone other than the patient be participating in the assessment? *

Yes
No

Surname *

First Name *

Contact number *

Relationship to patient *

Interpreter required? *

Yes No

Preferred language *

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Medical

Date of hospital admission *

Reason for hospital admission *

Medical background *

Infection precautions *

Medical/surgical precautions/recommendations *

Is the patient on dialysis? *

Yes No

Please provide details on location, days attending and transport plan (please note that TACP does not assist with dialysis transport) *

Will the patient be discharged on home oxygen? *

Yes No TBC

Is this pre-existing or new on discharge? (Please note TACP can not provide or organise home oxygen) *

New Pre-existing

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Cognition & Mental Health

Are there any concerns regarding the patient’s cognition? *

Yes No

Please provide details (e.g. formal diagnosis, cognitive assessment results, family/treating team concerns, etc) *

Are there any concerns regarding the patient’s mental health? *

Yes No

Please provide details (e.g. diagnosis, is this self managed? Is patient known to a mental health service? Who will manage patient’s mental health on discharge?) *

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Nursing

Will the patient be discharged with *

IDC
SPC
Stoma
Nil

Provide Details - IDC

(e.g. patient independent with management/who will assist with management)

Provide Details - SPC

(e.g. patient independent with management/who will assist with management)

Provide Details - Stoma

(e.g. patient independent with management/who will assist with management)

Will the patient have any nursing requirements on discharge? *

Yes No TBC
(Please note that patients accepted by SLHD TACP can not have involvement with Sydney District Nursing or HiTH. TACP can only provide nursing maximum 3 x week Monday- Friday only)

Name of Nursing Unit Manager/RN *

Email of Nursing Unit Manager/RN *

Please provide details of nursing requirements and frequency on discharge *

Does the patient have any existing pressure injuries or are they at high risk of pressure injuries? *

Yes No

Please provide details (e.g. Waterlow score, skin assessment, equipment, etc) *

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Current Function

Please note that TACP is a low level program (Monday - Friday only) – therefore patients will need to be independent with mobility, transfers, dressing, toileting, medication management and simple meal preparation if they live alone or have no informal assistance.

Please comment on patient’s current function, noting aids used and level of assistance required.

Transfers *

STS *

Indoor mobility *

Outdoor mobility *

Stair mobility *

Toileting *

Continence *

Showering *

Dressing *

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TACP Therapy and Service Provision

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Additional Information

Additional Information(e.g. complexity issues)

Required!