Living Well After Stroke expression of interest

Are you over the age of 18?

YesNo

In which State/Territory do you live?

Unfortunately, you are ineligible for the

Living Well After Stroke program.

**CURRENTLY THE PROGRAM IS ONLY AVAILABLE IN TASMANIA**

****Please email the LWAS coordinator if you would like to be

contacted once it is available in other states****

EMAIL: lwas@strokefoundation.org.au

Our apologies for any inconvenience.

For free information, advice and support, please call Strokeline

on 1800 787 653 or email at strokeline@strokefoundation.org.au.

They can help you find the support and services you need.

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

Phone Number

Delay in LWAS Commencement

Diagnosis and any information relevant, of Person you are referring

Carer or Family Details

Name (of who is filling out this form)

Phone Number

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

When did you have a Stroke or TIA?

Which of the following rehabilitation services were you referred to after your stroke or transient ischemic attack (TIA)?

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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