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Make a referral

Refer yourself, a family member or a participant. Our team will review the information and contact you about next steps.

Referral form

Tell us how we can help

Fields marked * are required. Please do not include highly sensitive medical documents in this first enquiry.

Your name *

Your relationship to participant *

Email *

Phone *

Participant name *

Participant age range

Suburb or service area *

Primary service requested *

Funding management

When is support needed?

Support needs, goals and preferred schedule *

I confirm I have authority or consent to make this referral and agree to be contacted about it. *

For urgent danger or a medical emergency, call 000. This form is not monitored as an emergency service.

Acknowledgement of Country

Medease Health Care acknowledges Aboriginal and Torres Strait Islander peoples as the Traditional Custodians of the lands and waters where we live and work. We pay respect to Elders past and present and recognise the continuing connection to culture, community and Country.

We are committed to culturally safe, inclusive and respectful service delivery.

Make a referral

Tell us how we can help

Acknowledgement of Country

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