Blog Referral Careers Contact

Private Care Referral

Complete this form to refer a client for privately funded care services with flexible and personalized support options.

Private Care Service Referral Form

Referrer Information

Full Name *

Organization

Position/Title

Email Address *

Phone Number *

Relationship to Client *

Client Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Emergency Contact Name *

Emergency Contact Phone *

Home Address *

Client has a Representative (Guardian, Power of Attorney, or Support Person)

Private Care Service Requirements

Payment Method *

Services Required * (Select all that apply)

Personal Care & Hygiene

Companionship & Social Support

Housekeeping & Cleaning

Meal Preparation & Shopping

Transportation & Appointments

Medication Reminders

Specialised Care (Post-surgical, Recovery)

Level of Care Required *

Preferred Schedule *

Urgency Level *

Medical Conditions & Care Requirements *

Personal Preferences & Requirements

Client has NDIS Funding

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

Supporting Documents

Insurance Documentation

Upload private health insurance cards, WorkCover documentation, or other relevant insurance information

Medical Reports/Assessment

Upload recent medical reports, discharge summaries, or care assessments

Additional Information

Consent and Authorization

I confirm that I have authorization to make this referral on behalf of the client and that all information provided is accurate to the best of my knowledge. *

I acknowledge that this information will be used for private care service delivery and understand the fee structure will be discussed during the assessment process. *

What Happens Next?

Initial Consultation

Our care coordinator will contact you within 24 hours to discuss requirements and arrange an in-home assessment.

Care Plan & Pricing

We'll develop a personalized care plan with transparent pricing based on your specific needs and preferences.

Service Commencement

Once approved, we'll match you with qualified care professionals and begin services at your preferred schedule.

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

Here for you, here for Queensland. Comprehensive healthcare services across Queensland. From aged care to NDIS support, we're here to help you live your best life.

0428 950 043

Hello@clinicareqld.com.au

Queensland Wide