CC Referral Form

1
By proceeding, you consent to Cross Care Group collecting, using and storing your personal information in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs), and as set out in Cross Care Group’s Privacy Policy.
2
What is your relationship to the client?* This field is required.
Support Coordinator / Plan Manager
Healthcare Practitioner / Clinician
Hospital / Discharge Planner
Family Member / Friend
I am referring myself (self-referral)
Other
3
Referrer Details
Full Name
Company/Organisation (Optional)
Phone Number
Email
4
Client Details
Full Name
Phone Number
Email
5
Client Date of Birth
Date
Day
Month
Year
6
Client Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Client's Primary Contact* This field is required.Who is the primary contact for the client? This person will be contacted to help arrange appointments.
Referrer
Client
Other
8
Other: Client's Primary Contact DetailsPlease specify
Full Name
Specify your relationship to the client
Company/Organization (Optional)
Phone Number
Email
9
Client Emergency Contact
Full Name
Relationship to client
Phone Number
Email (Optional)
10
How will this service be funded?* This field is required.
NDIS Plan
Private Health / Injury Insurer (e.g., iCare, NIISQ, TAC)
Self-funded / Private
Other
11
Funding Period(e.g. 3 monthly, 6 monthly, etc)
12
NDIS Participant Number* This field is required.
13
NDIS Plan Start Date* This field is required.
Date
Year
Month
Day
14
NDIS Plan End Date* This field is required.
Date
Year
Month
Day
15
Please list the relevant NDIS goals this referral will supportPlease list exactly as they appear on the client's official NDIS plan.
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Large
Normal
Small
Ok
Ok
16
Plan Management Details* This field is required.
Self-Managed
Plan Manager
NDIA/Agency Managed
17
Self-Managed Plan Details* This field is required.
What email address are invoices to be sent to?
18
Plan Manager Details
Organisation Name
Phone Number (Optional)
What email address are invoices to be sent to?
19
Insurer Details
Insurer Name
Claim Number
Case Manager Name & Contact Email (if known)
20
Which Community Care services do you require? (select all that apply)
Personal Care
Palliative Care
Tracheostomy Care
Catheter Management
Complex Bowel Therapy
Enteral Feeding and Management
Complex Wound Management
Advanced Airway Management
Ventilation Care & Management
Bariatric Management
Medication Management
Diabetic Management
Oncology Management
Complex Cognitive Impairment Support
Continence Assessment
Allied Health Assessments
Other
21
Which Allied Health Assessment services do you require? (select all that apply)These will be delivered by our Allied Health Division.
FCA - Funcational Capacity Assessment
AT - Assistive Technology Assessment
Home Modifications Assessment
SIL - Supported Independent Living Assessment
SDA - Specialist Disability Accomodation Assessment
ILO - Independent Living Options Assessment
Home & Living Options Asessment - Explore Suitable Living Options
Manual Handling Plan
22
Referral Details. Please describe the client's current situation, functional challenges, and what you hope to achieve with this referral.Include any relevant medical history or diagnoses.
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Large
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Ok
23
How would you rate the urgency of this referral?
Standard: Routine assessment needed.
Medium: Client has clear needs impacting daily life.
High: Significant risk of harm, hospital admission, or breakdown of supports.
24
What is the preferred method of service delivery?
In-Home Visit
Telehealth
A mix of both (hybrid)
Other
25
Diagnoses
Primary Diagnosis
Secondary Diagnoses/Background (What is the client's secondary diagnosis (if any). Please list all relevant health conditions)
26
Current supports in place* This field is required.What supports does the client currently have in place? Please list role and contact details. Examples include: support workers, carers, family, allied health practitioners, medical specialists.
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Small
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Ok
27
Risks/alerts
Falls risk
Pressure injury
Dysphagia
Behaviours of concern
Infection risk
Allergies or alerts
None
Other
28
Supporting DocumentsTo help us process this referral faster, please upload any relevant documents. Examples include: GP reports/letters, psychologists reports, hospital documents, physio report, medication lists
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