Support at Home Referral Form

NDIS Referral FormSupport at Home Referral Form

Support at Home Referral Form

Complete this form to refer yourself or someone else to Dolare Care for Support at Home services.

Takes approximately 3–5 minutes.Fields marked * are required.

Step 1 of 4

1. Who is making the referral?

I am referring myselfI am referring someone else

2. Referrer/contact details

Full name *

Relationship/organisation *

Phone *

Email *

3. Client details

Full name *

Date of birth *

Suburb/postcode *

Phone Optional if an email is provided

Email Optional if a phone number is provided

Preferred language Optional

Please provide at least a client phone number or email address.

Add representative details

Representative’s full name *

Representative’s phone

Representative’s email

Provide at least a phone number or email address.

Please provide the representative’s phone number or email address.

4. Support at Home status

Where are you currently in the Support at Home process? *

Current provider Optional

Complete these fields only if a care manager is involved and their details have not already been provided as the referrer.

Care manager’s name

Organisation

Phone

Email

6. Consent and submission

Best person to contact *

ClientRepresentativeReferrerCare manager

We do not yet have contact details for the selected person. Please provide them below.

Contact name *

Phone

Email

Please provide a contact name and either a phone number or email address.

I confirm that I have the client’s consent or appropriate authority to submit this referral and share this information with Dolare Care. I have read the Privacy Policy.
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