Aged Care Service Referral Form

Referrer Information

Full Name *

Organization *

Position/Title *

Email Address *

Phone Number *

Client Information

First Name *

Last Name *

Date of Birth *

Phone Number

Email Address

My Aged Care Client Number

Home Address *

Aged Care Service Requirements

Service Level Required *

Services Required * (Select all that apply)

Personal Care (showering, dressing, medication)

Domestic Assistance (cleaning, laundry, shopping)

Social Support & Community Access

Respite Care

Meal Preparation

Aged Care Assessments into aged care

Urgency Level *

Medical Conditions & Mobility *

Current Support Network

Client has NDIS Funding

Check this if the client will be using NDIS funding for services

Supporting Documents

My Aged Care Assessment/Referral

Upload My Aged Care assessment or referral documentation if available

Medical Reports/Care Plans

Upload relevant medical reports, care plans, or discharge summaries

Additional Information

Consent and Authorization

I confirm that I have the client's consent to make this referral and that all information provided is accurate to the best of my knowledge. *

I acknowledge that this information will be used for the purposes of care coordination and service delivery, and may be shared with relevant healthcare providers as necessary. *

What Happens Next?

Initial Review

Our intake team will review your referral within 24 hours and contact you to confirm receipt.

Assessment Coordination

We'll coordinate with My Aged Care and arrange a comprehensive assessment if needed.

Service Commencement

Once approved, we'll develop a personalized care plan and commence services according to the client's needs.

Aboriginal and Torres Strait Islander cultural imagery

Acknowledgment to Country

Clinicare QLD acknowledges the First Peoples of this Nation and their ongoing cultural and spiritual connections to the lands, waters, seas, skies, and communities.

We acknowledge First Nations Peoples as the Traditional Custodians and Lore Keepers of the oldest living culture and pay respects to their Elders past and present.

Unity in Diversity • Respect • Recognition

Aged Care Referral