NEUROSCIENCES UNIT (NSU)

REFERRAL TO HUNTINGTON’S DISEASE PROGRAM

CONFIDENTIAL

Please complete form in Microsoft Word & return via email to: Graylands.Neurosciences@health.wa.gov.au

To complete the form, type in the grey fields (you don’t need to click in the grey field or make the cursor appear) or click the relevant boxes. Save the changes and email the saved document as an attachment.

If you are a medical specialist, you may provide a detailed clinic letter in lieu of this referral form provided it captures all key information.

Please note the following when making this referral: Our Huntington’s disease program is a specialist statewide multidisciplinary service providing assessment, diagnosis and continuing care to individuals with diagnosed or suspected symptomatic Huntington’s disease (HD). The support provided is specific to the individual’s HD diagnosis and related symptoms. It is not a substitute for ongoing primary health care by a GP or other relevant specialist medical and/or mental health services. The multidisciplinary team (MDT) consists of Consultant Neurology, Consultant Psychiatry, Social Work and Speech Pathology. If considered relevant to clinical management, the MDT may internally refer the client for clinical neuropsychology assessment. By referring to the program, it is understood that the referrer is seeking NSU specialist medical assessment and management in the context of the individual’s HD workup and related care. In all cases this will include NSU Consultant Neurology +/- Consultant Psychiatry. Other clinical needs will be determined by the MDT at point of referral with access to Social Work & Speech Pathology available based on the team’s assessment of the referral information, with the client waitlisted accordingly at this point. Beyond the initial referral, clinical needs will be assessed ongoing and internal referrals between NSU disciplines can be initiated as clinically indicated. Referrals to this program can be made by the individual themselves, family/friends (with the individual’s consent), legal guardians, medical doctors, allied health professionals and/or relevant support groups (e.g., Huntington’s Australia). If you have any questions about a potential referral, please contact NSU on 6159 6464.

DATE OF REFERRAL:
CLIENT DETAILS:
Surname:	First Name/s:
DOB:	Gender:
Mobile Number:	Home Number:
Address:
Email Address:
Language(s) spoken:	Interpreter Required:	☐ Yes ☐ No
Is the client of	☐ Aboriginal and/or ☐ Torres Strait Islander origin
Is the client aware of this referral? ☐ Yes ☐ *No, (please give reason) *The client must be aware of the referral and willing to engage with our service. Alternatively, if the client has a Guardian or enacted Enduring Guardian for medical decision making, the Guardian/Enduring Guardian must be aware and give consent.
CARER/SUPPORT PERSON DETAILS (if applicable):
Surname:	First Name/s:
DOB:	Gender:
Mobile Number:	Home Number:
Address:
Email Address:	Relationship to client:
Language(s) spoken:	Interpreter Required:	☐ Yes ☐ No
GUARDIANSHIP:
Does the client have a Guardian or Enduring Power of Guardianship (EPG) with the function of medical decision making? ☐ Yes ☐ No If yes, Name: Email: Phone: If an EPG, is this document currently in effect? ☐ Yes ☐ No Has the Guardian / Enduring Guardian consented to this referral? ☐ Yes ☐ No
BEST PERSON TO CONTACT TO BOOK THE APPOINTMENT:
☐ Client	☐ Other – client has consented to contact with: Name: Relationship: Phone:
REFERRAL INFORMATION:
Referral question (choose from below): ☐ Diagnosed with symptomatic Huntington’s disease and seeking transfer of care to NSU’s HD program for ongoing management. ☐ Concerned about emerging symptoms of Huntington’s disease and seeking assessment/diagnosis and management by NSU’s HD program. ☐ Other: Please note, if this referral is for predictive genetic testing for Huntington’s disease in the absence of any concern regarding current symptoms, refer to NSU’s Predictive Genetic Testing referral form instead.
Is there a known family history of HD? Please provide details.
What are the current symptoms and concerns? Please include details regarding motor, cognitive and psychiatric symptoms, any psychosocial concerns and any immediate risks.
RELEVANT PAST MEDICAL & MENTAL HEALTH HISTORY:
RECENT INVESTIGATIONS:
(e.g., results of any relevant genetic testing, brain imaging, bloods etc) Please attach any available imaging reports or other test results
RELEVANT SOCIAL HISTORY:
CURRENT MEDICATION REGIME:
Name, current dose, length of use:
CURRENT SERVICES/SUPPORTS & FUNDING:
Does the person receive any disability, aged care or related funding?	Yes: ☐ No ☐ Unknown ☐ NDIS funding ☐ My Aged Care funding ☐ Disability Support Pension ☐ Other:
Is the person known to Huntington’s Australia?	☐ Yes ☐ No ☐ Unknown
Is the person linked in with any other support/advocacy groups? (If yes, provide details.)	☐ Yes: ☐ No ☐ Unknown
Are there any other Health/ Mental Health services currently involved? (If yes, provide details.)	☐ Yes: ☐ No ☐ Unknown
OTHER RELEVANT ISSUES:
Are there any medicolegal issues? ☐ No ☐ Yes (please provide details):
Are there any other issues we should be aware of? (e.g., SAT hearing, patient going overseas, planned inpatient admission or discharge, relevant forensic history, any risks to Health workers). If so, please detail.

REFERRER’S DETAILS:
Name:	Position/Title:
Service/Agency:	Address:
Contact number:	Email:
If Registrar, provide Consultant’s details:

GP’S DETAILS:
Does the person have a current GP?	☐ Yes ☐ *No *Please note, we highly recommend our clients establish a relationship with a GP to optimise continuous and holistic care.
If not the referrer, please include GP’s details below:
Name:	Position/Title:
Clinic/Practice:	Address
Contact number	Email:

Please return this form via:

Email (preferred) Graylands.Neurosciences@health.wa.gov.au

Faxed to us directly on 9385 6813 or posted to:

Post Office Private Bag No.1 CLAREMONT WA 6910