Submit a Referral

Referral date

Patient name*

Date of birth

Is the patient under 18?

Yes

No

Are there any court orders about this child and their care? (shared custody arrangements, etc.)

Yes

No

Upload court order details

PDF, Word or image, up to 10 MB.

Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 10 MB.

Patient phone*

Patient email

Street address

Town / suburb

Postcode

Who is making this referral?*

I am referring myself

I am referring a family member or friend

I am a medical practitioner referring a patient

I am an allied health practitioner referring a patient

I am an insurer referring a client

I am an employer referring an employee

Other

Your name

Your contact number

Practitioner's name

Practitioner phone

Practitioner email

Practitioner postal address

Intended funding

Mental Health Care Plan

Private Health Insurance Cover

Self Funded - Private (not Medicare or Private Health Cover)

Workcover

Other Third Party

Anything else we should know?