Referrals

Make a Referral

Whether you're referring yourself or someone you support, this form captures everything our team needs to get started. It takes about ten minutes. Prefer to talk it through first? Give us a call.

Prefer to refer by phone?

1800 95 97 98

Mon to Fri, 9:00 AM to 5:00 PM AEST

Our team can help you complete a referral over the phone if that is easier for you or the person you support.

Everything in one form

Participant, cultural, service, and NDIS details, captured in a single guided form.

Handled with care

Your information is sent securely to our team and handled in line with our Privacy Policy.

Quick response

We review every referral and get in touch within one business day.

Referral form

Fields marked with an asterisk are required. The more you can tell us, the better we can prepare for the first appointment.

1Getting Started

Let us know who this referral is for.

I am completing this for*

Myself as the participantSomeone I am referring to EmpAura Care

2Participant Details

First name*

Last name*

Date of birth*

Gender*

Home address*

Participant phone number*

Participant email address*

Participant NDIS number*

Does the participant have a legal guardian / nominee?*

YesNo

3Cultural Details

Participant country of birth*

Does the participant require an interpreter?*

Relevant cultural or religious considerations (if any)

Does the listed participant identify as Aboriginal or Torres Strait Islander?*

4Services Request

Type of primary service required*

Number of hours requested for service*

Type of secondary service required

Additional service required

Participant's relevant conditions / disability (please list)*

Extra information that may assist with preparation for the initial appointment

Special assessments or therapies required

Notes for practitioners (additional relevant details)

5Booking Details

Preferred consultation type(s)*

In ClinicIn Home ServiceTelehealthCommunity

Who should we contact to make an appointment?*

Notes for reception staff (if applicable)

6NDIS Information

Participant's NDIS plan type*

I consent to EmpAura Care collecting and using the personal and health information in this form for the purpose of assessing and providing supports. I understand this information will be handled in line with the Privacy Policy. Where I am referring someone else, I confirm I have their permission to share these details.

On submit we generate a PDF of this referral and email it securely to our team. You can download a copy on the next screen.