Make a referral without the back-and-forth

Use this form to send a referral to AmizaCare. Include the practical details that help us check service fit, availability and next steps.

Referral details

Only send information you have consent or authority to share. Do not use this form for emergencies or immediate medical concerns; call 000 in an emergency.

Participant name

Participant suburb

Contact person

Contact role

Contact email

Contact phone

Plan type

NDIS numberOptional

Requested support

Urgency

Participant goals and what support should achieve

Risks, health needs, behaviour support or access information

Communication preferences

Preferred days or times

Consent and people approved for contact

I confirm I have consent or authority to share this referral information with AmizaCare.