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Make a referral

Make a referral

If you would like to enquire about our services before making a referral,
you can get in touch by the below methods:

Email: info@carerehab.com.au

Phone: 0483 842 315

We look forward to working with you.

Referral form

Client details

Client's First Name *

Client's Last Name *

Client's Date of Birth *

Client's Gender *FemaleMaleAnother Term

Client's Email *

Client's Mobile Phone *

Client's Street Address *

Client's City/Suburb *

Client's State *

Client's Post Code *

Client's Occupation *

Client's Diagnosis *

Client's Date of Injury

Client's Participant Number / Claim Number

Client's Contact Person Full Name

Client's Contact Person Mobile

Does the client need an interpreter? *YesNo

What language does Client mainly speak at home? *

Referrer Details

Referrer's First Name *

Referrer's Last Name *

Referrer's Email *

Referrer's Phone *

Referrer's Organisation *

Referrer's Position *

Reason for Referral *Psychosexual TherapySocial WorkSexual Wellbeing Facilitation / BootyrideLow-Cost CounsellingOther

Summary of client goals *

Would you like us to call you before we contact the client? *YesNo

Are there any safety concerns and/or behaviour of concern that we need to be aware of? *

Other people involved in the client care *

Timeframe you would like this assessment completed *Urgent <1 weekNot urgent 1-4 weeks

Client's preferred time/day for appointments *

Best person to contact for appointments *

Are there any other important things you believe we need to know to work effectively with this client?

How did you find out about Care Rehab?Case ManagerReferralInternet

NDIS Plan Details

Client's NDIS Number

Client's NDIS Plan Start Date

Client's NDIS Plan End Date

Who will sign the Service Agreement?

How is the Plan managed?Plan-managedSelf-managedPlease note that we are currently only accepting NDIS-funded clients who are plan or self-managed.

NDIS Plan Management Details (if applicable)

NDIS Plan Goals

Documentation

Upload file

Drag and Drop (or) Choose Files

Please provide all documentation relevant to this referral.

In the spirit of reconciliation, we acknowledge the Traditional Custodians of country throughout Australia and their continuing connections to land, sea and community. We acknowledge the Wallumedegal people of the Darug nation who are the Traditional Custodians of the land where we work and live. We pay our respects to Elders past, present and emerging, and extend that respect to all Aboriginal and Torres Strait Islander peoples today. We recognise that sovereignty was never ceded. This was and always will be Aboriginal land.

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