Adult Continence Referral Form Customer Name(Required) First Last Date of Birth(Required) Day Month Year Age(Required)Diagnosis(Required)Funding(Required) NDIS DSCA Other Address(Required) Street Address Suburb State Primary Contact Name(Required) First Last Email(Required) Primary Contact Address (if different from above)Referrers First Name(Required)FirstReferrers Last NameLast Relationship to Customer(Required) Parent Therapist Support Coordinator Other Referrers Contact Number(Required)Do you have permission from the primary carer? Yes No Toileting BehavioursType of incontinence(Required) Bladder Bowel Both Does the customer require assistance with toileting?(Required) No Partial Assist Full Assist Does the customer indicate a need to use the toilet?(Required) Yes No Does the customer display anxiety or behaviours of concern about using the toilet?(Required) Yes No Does the customer have mobility or sensory restrictions that interfere with their ability to sit on the toilet safely?(Required) Yes No Does the customer frequently soil their pants throughout the day?(Required) Yes No Bowel HistoryDoes the customer experience symptoms of constipation?(Required) Yes No Does the customer struggle to open bowels, withholds, has pain with bowel motions, or has frequent abdominal pain?(Required) Yes No Does the customer use any laxatives?(Required) Yes No Bladder HistoryDoes the customer have wetting accidents during the day?(Required) Yes No Does your customer wet their bed at night?(Required) Not at all 1 - 2 night per week 3 or more times per week Every night Do they wake up afterwards?(Required) Yes No Current Continence Products used (if any); None Nappies Pads Liners Bedding Protectors Other Are they effective? Yes No Name of product used and size.How many are used during the day?How many are used during the night?Please provide any additional Information relating to current toileting concernsHow did you hear about us?(Required) Google Social Media Customer Testimonial Email Referral Other Who referred you to Rocky Bay? Δ
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