← All referral forms Aged Care Referral

Aged Care referral form

For older adults accessing support through Support at Home aged care funding. Please complete the form below with as much detail as possible so our team can arrange the right in-home support. If you're unsure about any sections, leave them blank and we'll follow up.

Assessment priority

Urgent (1–2 days) ASAP (3–7 days) When convenient (7+ days)

Client details

Tell us about the person being referred for support.

First name *

Last name *

Preferred name (optional)

Sex

Date of birth

Phone *

Address line 1

Suburb / Town

State

Postcode

How should we organise the first visit?

Contact the client directly No, contact another person (provide details below)

Would the client prefer a family member or support person present during the assessment?

No Yes – the contact person listed above Yes – other

Funding & reason for referral

Funding source

Reason for referral / supports requested

Daily Personal Activities Household Tasks Community Participation Community Nursing Care Travel & Transport Social Support

Presenting needs / relevant medical history

Background & current social supports

Home visit & access

Are there any risks for home-visiting staff?

Yes No

Referrer / coordinator details

The person completing this form. You can refer yourself, or on behalf of someone else.

Your name *

Your email *

Your phone

Provider / company (if applicable)

Upload the ACAT / SAS report (optional)PDF, Word or image. Max 8MB.

Any other relevant document (optional)