Make a Referral

Just Fill out our easy step-by-step referral form below. If you need any assistance while completing the form, you can request a call back at any time by clicking the Call Back button. If you'd prefer to discuss your referral directly, our friendly team is here to help. You can reach us at +61 405 306 094 or email us at info@recoverycareaustralia.com.au, and we'll get you started.

Select Your Choice

I am a Participant

I am a Referrer or Nominated Representative

Please select an option.

Participants Details

First Name This field is required.

Last Name This field is required.

Preferred Name

Preferred Gender

Preferred Pronoun

Date of Birth This field is required.

Post Code

Suburb

Home Address

Reason for Referral

Service Required

Select a required service Please select a service.

How would you/participant prefer to receive our services

Diagnosis / Condition

NDIS plan details

Do you have an approved NDIS plan or are you awaiting approval? Please select an option.

Participant's Contact Details

Please note that the contact details inputed here will be contacted, whether you are the referrer or participant.

Name This field is required.

Email Please enter a valid email.

Phone This field is required.

Address

Is there a guardian involved?

Yes No

Thank You!

Your referral has been submitted successfully. We will be in touch shortly.