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Referring Clients to Alpha Nursing

Alpha Nursing accepts referrals from any healthcare organisation for clients who would benefit or require care in the home to maintain independence or interventions for complex care needs.

We can assist clients with Appointment Escorts, Hospital in the Home, Wound care and Light Domestic Duties.

Alpha accepts referrals for clients who are funded by the Hospital, DVA, NDIS, A Care Package Provider or from clients who are funding their own care. More information about submitting your referral and forms can be found on this page.

Submitting your referral

You can submit your referral using any of the methods below. Please contact us on 1300 493 608 if you have any questions regarding your referral.

Online

You can refer online by completing the online form located at the bottom of this page

Email

Please email referral and any supporting documents to homecare@alphanursing.com.au

Fax

You can fax your referral and supporting documents to (03) 9331 7519

Forms

Referring clients to Alpha Nursing

The following form can be used to make a referral to Alpha Nursing

Community Service Request – Referral Form.pdf

Home Care Client Handbook

The home care client handbook outlines Alpha Nursing's home care service

Home Care Client Handbook.pdf

Please use the DVA Community Nursing Referral form D9389 for referring Community Nursing available from the Department of Veterans’ Affairs website

Community Service Request / Referral Form

Requesting provider details

Hospital / Referring Organisation:

Date:

Referrer Name:

Fax:

Phone:

Email:

Please indicate if you would like a referral receipt: Fax Email Phone Not Required

Client details

Name:

Date of Birth

Gender:

Address:

Phone:

Email:

Primary contact: Client Carer Co-ordinator

Primary Contact Phone:

Primary Contact Email:

Emergency contact:

Relationship to client:

Emergency Contact Phone:

Emergency Contact Email:

Service & site information

Interpreter required:

Yes No

Preferred language:

Has the client been hospitalised within last 30 days?:

Yes No

Discharge / estimated discharge date:

Aboriginal or Torres Strait Islander?:

PPE measured required?:

Is the client aware of this request & has consent been obtained to share information?

Yes No

Please attach with form

Home & Environment

Home Safety Checklist conducted?

Yes No

Please attach with form

Emergency Plan available in the home?

Yes No

Preferred room to conduct service?:

Is safe parking available?

Yes No

Close to premises, adequate lighting

Is there a key lock box?

Yes No

Code:

Are there hazards/obstructions accessing the home?

Yes No

Preferred entry door point?:

Are there pets on premises?

Yes No

Quality of mobile phone coverage at site:

Accommodation

Own Home Renting SIL Other housing

Access

Stairs Lift Ramp Intercom

Potential Risks

Violence or harm to water Drug or alcohol dependence Behavioral concerns Firearms/weapons Dangerous pets Home safety / WHS concerns

If any risks are identified to the worker or client, we will contact you to discuss appropriate management strategies. Services may be delayed.

Service Requirements

Personal Care: Yes

Nursing Care: Yes
Clinical care charts to be made available e.g. Wound care pathway etc.

Medication Administration Required?: Yes
Medication chart must be available tor nurse to sign on premises. This chart can be provided on request

Community Access: Yes

Comprehensive Nursing Assessment - Minimum 4 Hours: Yes

Please attach a copy of health summary, ACAT and nursing/support plan if available

Nursing Assessment: Yes

Type:

Service Notes

Minimum booking period of 2 hr for all services unless a run of 2 or more clients is provided.

Travel charges apply if a carer vehicle is used for transport.

Wound consumables to be provided/ordered by client or referrer unless otherwise agreed.

Refer to fee schedule for full terms and conditions

Please return completed referrals to: homecare@alphanursing.com.au or fax to (03) 9331 7519

Service Request Details:

Include details of required services including dates, times, and tasks/services to be completed.

Medical History:

Allergies:

Payment/Invoicing for requested services

Invoice to referring provider Invoice to another provider Invoice to client direct

Funding Provider Name:

Client ID Number:

(e.g. NDIS, DVA etc. if applicable)

Name / Department:

Contact Phone:

Address for invoices:
Email address for invoices:
Comments:

File Upload

Please upload your supporting documentation in a single pdf, word or excel format (max 10mb) or email to homecare@alphanursing.com.au

Authorisation

Name:

Role:

Date:

By checking this box you agree that the information you are providing to Alpha Nursing complies with information sharing regulations and that the information you have provided is true and correct
I Agree Yes

About Alpha

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Application Process

Victoria

Head office
8 Centreway,
Keilor East, Victoria 3033

South Melbourne
232 Albert Road,
South Melbourne, Victoria 3205

1300 493 608
recruitment@alphanursing.com.au

South Australia

242 Glen Osmond Road,
Fullarton, SA 5063

(08) 7129 5032
recruitment.sa@alphanursing.com.au

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