Carer Gateway Support Referral

If you are a carer, or someone you know is a carer of an individual who has;

  • A disability; or
  • A life limiting health/medical condition; or
  • A mental illness; or
  • Is frail and aged 

please complete this referral form. 

To understand how we collect, use and store your personal information, please see our Privacy Collection Notice.

You can also get more information about our processes in our Privacy Policy.

Carer Gateway Support Referral Form

Website Referral
Are you a carer?* - required
About the carer
About the Carer
Gender* - required
Employment Status* - required
Carer Status* - required
Is an interpreter required?* - required
About the Care Recipient
About the Care Recipient
Does the Care Recipient live at the same address as the carer?* - required
Care Recipient address
Carer Recipient Details Continued
Type of funded plan/ package (NDIS/ My Aged Care) (if applicable)* - required
Home Assessment Completed?* - required
About the referrer
About the Referrer
I have consent from the client to make this referral* - required
Does the Referrer want to be contacted about the outcome* - required
Are there any identified risks to the carer or care recipients?* - required
Consents
Please read and give your final consents below before submitting this form.
Consent to share your de-identified information (i.e. no names shared)* - required
Carer has consent to act on behalf of the person they care for? (i.e. organise and set up services etc.)* - required
Consent to have personal information stored in The Benevolent Society database* - required
Consent to participate in follow-up research, surveys and evaluation* - required
Mandatory field(s) marked with *