Disability Services Referral

If you know someone with disability who would benefit from assistance or would like to refer yourself, please complete this referral form.

To know 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.

About you - The Referrer

About you - The Referrer

I have consent from the client to make this referral* - required
About the client
About the client
Can the client be phoned?* - required
Gender* - required
High risk?* - required
Interpreter Required?
Does the client identify as Aboriginal or Torres-Strait Islander or both?* - required
Client Plan Details
Client plan details
How is plan managed?
Support Required
Support Required* - required
Background information
Carer/ Support/ Guardian
Carer/ Support/ Guardian Information
Does the client have a care/ support person?* - required
Communications Contact
Communications Contact Information
Who is the best communications contact?* - required
New Panel 2
I have read the privacy collection notice below and consent to The Benevolent Society contacting me regarding disability support services.* - required
Mandatory field(s) marked with *