Tool 14
Professional Referral Information Form
For referrers: the functional question, relevant goals, existing recommendations, barriers, learning needs and preferred collaboration method.
A good referral answers a functional question. This form gathers what IMHC needs to design safe, relevant learning: the reason for referral, relevant goals, existing recommendations that affect implementation, functional barriers and safety considerations, communication and learning needs, and current supports.
Please provide only information relevant to the functional learning question, and use an appropriate secure process for sensitive clinical documents.
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Professional Referral Information Form
Professional / Referrer Tool • PROFESSIONAL RESOURCE
| Field | Information |
|---|---|
| Referrer name / role | |
| Organisation (optional) | |
| Work contact | |
| Participant preferred name | |
| Consent / authority confirmed | |
| Functional question / reason for referral | |
| Relevant goals | |
| Existing recommendations relevant to implementation | |
| Functional barriers / safety considerations | |
| Communication / learning needs | |
| Current supports / involved professionals | |
| Preferred collaboration / review method |
Please provide only information relevant to the functional learning question. Use an appropriate secure process for sensitive clinical documents.
IMHC educational tool. Use within the person's agreed plan and professional recommendations. This resource does not replace clinical assessment, diagnosis, treatment or emergency support.