Make a Referral – EqualRise Healthcare

⚠️ This referral form is not monitored for emergencies. If someone is in immediate danger, call Triple Zero 000.

👤 Referrer Details

Full Name *

Organisation

Role / Position

Phone *

Email Address

Relationship to Participant

🧑 Participant Details

Participant Full Name *

Date of Birth

NDIS Number (optional)

Address / Suburb

Preferred Contact Method

Preferred Language

Interpreter Required?

Aboriginal and/or Torres Strait Islander Identity

This information is optional and only collected if the person wishes to share it.

🩺 Service Requested *

Support Coordination

Specialist Support Coordination

Behaviour Support

Allied Health / Therapeutic Supports

Community Nursing

Daily Living

Community Participation

Other

Other Service (please specify)

📋 NDIS Plan Details

Plan Management Type

Support Urgency

Plan Start Date

Plan End Date

Relevant Funding Category

📝 Reason for Referral

Current Needs

Goals

Risks or Safety Concerns

Current Providers Involved

✅ Consent

* Participant and/or guardian consent has been obtained for this referral.

Consent to contact the participant or referrer about this referral.

* Consent to collect and securely store the referral information.

Consent to share relevant information with stakeholders if required for service delivery.

Fields marked * are required to submit this referral.

📎 Upload Supporting Documents (Optional)

You may upload relevant documents such as NDIS plans, behaviour support plans, reports, risk assessments, or consent forms.

📁

Click to upload or drag and drop files here

Allowed: PDF, DOC, DOCX, JPG, PNG — Maximum 10MB per file

⚠️ Not monitored for emergencies. For emergencies, call 000.