Concussion Service

Auckland region - Adult, Child & Adolescent

SRS has a Concussion Service and accepts referrals from ACC, GP’s Accident and Emergencies/Medical Centres or hospital. We have an experienced team who can see children and adults aged from birth throughout adulthood. We can see those who have had a concussion in the last 12 months across the Auckland region - from Pokeno to Wellsford. Our team has a wealth of experience in working with children, families and adults following concussion or traumatic brain injury. The team assists and advises with a return to school or work and all usual activities as soon as possible.

The SRS team includes:

Jo Falloon - Occupational Therapist and SRS Concussion Service Lead - Child & Adolescent
Liz Irwin - Occupational Therapist and SRS Concussion Service Lead - Adults
Occupational Therapists
Physiotherapists
Speech and Language Therapist
Psychologists
Neuropsychologists
Medical Specialists

For further info about the service and the referral process please contact Jo Falloon or Liz Irwin on:

Jo Falloon - Child & Adolescent Service Lead

021 2484 212 or

Liz Irwin - Adult Service Lead

020 456 9000 or

Make a referral directly to us

Fill out the Adult Referral Form online

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Client details

Client name:

Claim number:

National Health Index (NHI) number:

Work phone number:

Home phone number:

Date of birth:

Address:

Was the client employed at the time of the accident? Yes No

Is the client off work? Yes No

Employer contact name:

Employer phone number:

Injury details

ACC45 number or claim number:

Date of injury:

Date of referral:

Date injury reported:

How many times have you or another provider (if known) seen this client for this traumatic brain injury?

Please attach clinical notes:

Is this concussion the principal injury or an additional injury?

Glasgow Coma Scale score:

Post-Traumatic Amnesia score:

What is your suspected injury diagnosis?

What is your confirmed injury diagnosis, including Read or ICD10 code?

Briefly describe how the injury occurred, e.g. the mechanism of injury:

Which of the following symptoms were present at the time of consultation? Please tick all that apply.

Loss of consciousness reported

Mood changes (e.g. depression, anger)

Loss of balance

Fatigue

Visual disturbances

Difficulty concentrating

Headaches

Muscular aches

Nausea

Dizziness

Memory problems

List any other symptoms that are relevant to this referral:

List any pre-existing factors that may impact recovery:

Referrer details

Referrer name:

Provider number:

Practice or department name:

Contact phone number:

Postal address:

If ACC does not need to allocate the provider, who is your preferred concussion service provider?

SRS Ltd – Vendor ID VAD363

If services are declined, please notify: referrer and/or GP (name):

Referrer declaration

If this referral includes a confirmed diagnosis of concussion, we need a qualified medical professional to sign it, e.g. a General Practitioner (GP) or Emergency Department (ED) physician. We will consider this electronically completed form to be signed by the doctor named in this section.

Referrer name:

Medical (ED, GP) Allied health, hospital

Date:

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When we collect, use and store information, we comply with the Privacy Act 1993 and Health Information Privacy Code 1994. For further details see ACC's privacy policy, available at www.acc.co.nz. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001.

Fill out the Child & Adolescent Referral Form online

Are you human?
Leave this empty if you are a human. This is to prevent spam.

Client details

Client name:

Claim number:

National Health Index (NHI) number:

Date of birth:

Home phone number:

Address:

Authorised client alternative contact name:

Relationship to client:

Contact phone number:

Email address:

Please check your email address for errors

Clinical Presentation

Date of injury:

Date injury reported:

Briefly describe how the injury occurred, e.g. the mechanism of injury:

Lowest Glasgow Coma Scale score 5-15years:

Lowest AVPU score (pre-school):

ACE score:

Positive preschool screen: Yes No

Positive SCAT5: Yes No Not done

Which of the following symptoms were present at the time of consultation? Please tick all that apply or alternatively attach ACE, or Child SCAT5.

Loss of consciousness reported

Mood changes (e.g. depression, anger)

Loss of balance

Fatigue

Visual disturbances

Difficulty concentrating

Headaches

Muscular aches

Nausea

Dizziness

Memory problems

ACE, or Child SCAT5:

Length of time to recover:

List any pre-existing factors or information relevant to this referral:

How many times have you or another provider (if known) seen this client for this traumatic brain injury?

Is this concussion the principal injury or an additional injury? The principal injury An additional injury

Diagnosis

Is the diagnosis of a traumatic brain injury? Unconfirmed but suspected and requiring investigation Confirmed and requiring clinical management and rehabilitation

Read or ICD10 code:

Referrer details

To refer this client you must be a medical professional or be working on the instruction of a medical professional. Please make sure the referring doctor is named.

If this referral is confirming or adding a diagnosis of concussion a qualified medical professional must sign this section. We will consider emailed forms completed electronically to be signed by the doctor named in this section.

Referring Doctor:

Who is: DHB medical staff GP

Attach clinical notes:

This referral has been completed by:

Practice or department name:

Contact phone number:

Postal address:

Who is your preferred concussion service provider? Note: ACC can allocate a provider. SRS Ltd – Vendor ID VAD363

If services are declined, please notify:

Referrer

GP name:

Referrer declaration

We will consider this electronically completed form to be signed by the doctor named in this section.

Name:

Date:

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Download the Adult Referral Form Download the Child & Adolescent Referral Form

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Concussion Service

Auckland region - Adult, Child & Adolescent

The SRS team includes:

Jo Falloon - Child & Adolescent Service Lead

Liz Irwin - Adult Service Lead

Make a referral directly to us

Client details

Injury details

Referrer details

Referrer declaration

Client details

Clinical Presentation

Diagnosis

Referrer details

Referrer declaration

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