REFERRAL FORM

It would be desirable to develop a system of referral from one level to the other
with laid down procedures and policies so that these institutions give required referral
services. It should be emphasized that referral is a two way process and that the retention
of patients in referral institutions should be as brief as possible.

DEFINITION:

Referral is a process of directing someone to another source of assistance. Referral is

the act or instance of sending or directing someone for treatment, aid, information or a
decision.

PRINCIPLES OF REFERRAL:

 The referral should meet the needs and objectives of the clients and should
be necessary and appropriate – there should be merit in referral.
 The client should be able to use the referral in an efficient, effective manner –
it should be practical.
 The referral should be individualized to the client.
 The referral should be timely.
 The referral should be coordinated with other activities.
 The referral should incorporate the client and family into planning
and implementation.
 The referred should have the right to refuse the referral

REFERRAL PROCESS IN COMMUNITY:

The referral process is a systematic problem solving approach involving series of

actions that help clients use resources for the purpose of resolving needs. Clients may be
individuals or groups who require assistance from others in order to achieve their maximum
level of functioning.
The basic steps of the referral process:

Establish a working relationship with the client. Define the need for a referral. Set
objectives for the referral. Explore resource availability. Client decides to use or not use
referral. Make referral to a resource. Facilities and follow up
 Referral form:

Date…………………

Name of the patient………………………………………………….

Father’s / Husband’s name…………………………………………………………………

Age………… Gender …………… Religion………………

Present diagnosis………………………………………

Case history in short…………………………………..

Description of treatment given………………………..

Date of sending for referral……………………………

Cause of sending for referral…………………………………………………………………

(Signature)

Name of the sender………….

Designation …………………