Living Well After Stroke expression of interest

Are you 18 years of age, or over?

Yes No

You must be 18 years or older to participate in LWAS

Unfortunately, being under the age of 18 years, makes you ineligible to join the Living Well After Stroke Program.

If you would like to discuss further, please email the coordinator: lwas@strokefoundation.org.au

Apologies for any inconvenience.

Who is completing this form?

This form is for me (self Referral)I am a carer or Family member Stroke Foundation Strokeline NavigatorI am a Health professional referring a client

Health Professional Details

Health Professional's Name

Clinic details

Email Address

Delay in LWAS Commencement

Is the patient aware of this referral being made on their behalf?

YesNo

Diagnosis and any information relevant, of Person you are referring

Carer or Family Details

Name (of who is filling out this form)

Phone Number

Email address

Are you the best person to contact

Diagnosis, and relevant details of person you are referring

Strokeline Navigator Referrer

Navigator's Name

Contact Email

Diagnosis, and any other relevant and useful information about person you are referring. e.g. family/carer involved if relevant behaviors, mental health concerns

Hidden Use Only

	True
Bypass Validation Rules (Patient Contact)
Bypass Validation Rules (GP Contact)
Bypass Validation Rules (Carer/Next of Kin Contact)
Form Auto-Assign (Case)
Health Record (Contact)

Business Hours (Case)

Record Type ID (Case)

LWAS Waitlist Queue ID

Case Type (Case)

Case Origin (Case)

Subject (Case)

Body

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