Referral to Parish Nurse Ministry

Client Name: Date: Visitor:

Possible Reasons for Referral	Y or N*	Comments
Lives alone and has obvious physical, emotional or economic challenges
Has the primary responsibility for care of a sick, impaired or dying person
Has an advanced illness or terminal condition
Recently experienced death of a loved one
Recent life changes such as retirement, moving, divorce, or disability
Lack of effective support system; may feel isolated, abandoned, lonely, insecure, etc.
Appears “frail” or “ill”
Fatigue or limited endurance
Limited mobility or is bedridden; may use assistive device such as cane, walker, wheelchair
Activities of daily living (ADLs): has difficulty but does by self, requires assistance or is dependent on someone else
May need help with transportation, shopping, business affairs, etc.
History of falls with injuries
Has home safety risk factors
Difficulty with vision, hearing or communication
Has multiple medications
Chronic or recent acute medical problems
Recent or planned upcoming surgery
Emotion/mood: Anxiety, stress, fear, sadness, anger, blaming, etc.
Difficulty with memory, problem-solving or understanding
Altered nutrition: weight loss, poor appetite, dental problems, special diet, food costs, etc.
Frequent or recurring pain
Lack of adequate rest or sleep
Spiritual distress or alienation

* Use N to indicate: “no,” “not known,” or “not observed”

Have you mentioned Parish Nursing to client? o yes o gave permission to call o no

If you left any brochures on community resources, what were they?