Forms

Inpatient Referral

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Patient Details


Address


Contact


Details

Sex*

Interpreter Required?

Aboriginal/Torres Strait Islander?


Next of Kin


General Practitioner


Health Found Details


Health information

Does the client have difficulty communicating?*

Is the client orientated?*

What is the clients weight bearing status?*


Rehabilitation Program

Type of Rehab Program*


Referral


Consent


Another Form

Day Rehabilitation

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Patient Details


Address


Contact


Details

Interpreter Required?*


Next of Kin


Health Found Details


Referrer Details


Primary Diagnosis


Current Status


Services Required

Minimum of 2 disciplines. Half Day Program: 1.5 hours, Full Day Program: 3 hours.

Hydrotherapy

Dietetics

Exercise Physiology

Occupational Therapy

Physiotherapy

Speech Pathology

PD Warrior

LSVT BIG

LSVT LOUD

Is Hydrotherapy recommended as part of client's rehabilitation program? If so a hydrotherapy clearance form will need to be signed by a medical officer.*


And another one

Volunteer

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Personal Details


Address


Contact


Details

Aboriginal/Torres Strait Islander?*


Volunteering


Work & Study

Are you working?*

Are you studying?*


First Emergency Contact


Second Emergency Contact


Work & Volunteering History

Have you volunteered in the past?*


Skills/Talents & Qualifications


Medical History

Do you suffer from any medical condition (injury, allergy, disorder, illness) that may impact your ability to perform volunteer duties?*


Volunteering Preferences

Royal Rehab has a range of volunteering opportunities and we will endeavour to match volunteers to enable us to provide quality services. Where would you like to volunteer? (You may tick several areas if you wish)*


Availability

When day would you like to volunteer?

Monday*

Tuesday*

Wednesday*

Thursday*

Friday*

Saturday*

Sunday*


Volunteering at Royal Rehab

How did you find out about volunteering at Royal Rehab?*


First Referee

Please provide two personal referees who are not relatives. Please ensure that your referees have been advised that they have been nominated to support this application and that you consent to them being contacted in regard to this application.


Second Referee


Consent

It is absolutely essential to treat any personal details of medical, social or family history of a patient as STRICTLY CONFIDENTIAL. Any information which may come into your possession by virtue of your volunteering is not to be divulged to unauthorised persons and you are to be particularly careful that you do not, even innocently, raise matters relating to any patient’s illness or personal details in general conversation.Royal Rehab takes a very serious view of failure to observe any breach of the patient’s privacy. This places both Royal Rehab and the individual concerned at risk of legal action and its consequences and may constitute grounds for dismissal.All external requests for patient information must be directed to your supervisor.*

Royal Rehab is a smoke-free workplace. Volunteer photo identification badges must be worn at all times. Where volunteer Polo Shirts are provided, volunteers are expected to wear these while volunteering. When uniforms are not provided, volunteers are expected to maintain an appropriate standard of dress as outlined in the Royal Rehab Uniform/Dress Code. Volunteers will be required to participate in appropriate WH&S and emergency management training to ensure their health and the health and safety of others who may be affected by their activities. iv. Volunteers are engaged by Royal Rehab under the terms and conditions of:a.Royal Rehab’s policies/practices b.Adhering to the Volunteer protocols and requirements, including completing online training modules.*

From time to time we take photos, videos, sound recordings and interviews of our volunteers for our promotional purposes.I give consent to:a) be interviewedb) have photographs taken of mec) have sound recordings made of me andd) be recorded on a video or to be filmedby Royal Rehab and any services it manages or by any contractors engaged by Royal Rehab.I understand all rights, including all present and future property rights, in the photograph(s), video, film, sound recordings and interview content will be the property of Royal Rehab. I give my consent for the photograph(s), video, film, sound recordings and interview content to be used in whole or partly by Royal Rehab in any media and in any publication, reproduction, transmission, distribution, performance, dissemination or display now in existence or in the future without any further reference to myself and without remuneration to myself.*


Successful volunteers will be engaged for a three-month trial period. If necessary, this will be reviewed at regular intervals by the Manager of Volunteer Services. The purpose behind this is to give you an opportunity to decide if Royal Rehab is the place you wish to be a volunteer. It also gives Royal Rehab an opportunity to decide if you are suited to this type of volunteering.


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