Referral Form | Outback Futures

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Referral form.

Medical and health practices, schools and agencies can use this form to refer clients to Outback Futures.

Once submitted, you will receive an email confirmation of your referral. We will then contact the client within 3 working days.

Alternatively,

download and print a blank referral form here.
send a referral letter:
- email support@outbackfutures.org.au
- fax 07 2145 8025.

If you are an individual wanting to make an appointment, you don't need a referral. You can contact us here.

Referral Form

Client Information

Client First Name *

Client Last Name *

Client Date of Birth *

Client Age *

Client Gender

Client's Details (17 & over)

Client Phone

Client Email

Client Address

Contact client by

phone call

text

Parent or Guardian Details (16 & under)

Parent / Guardian Name

Parent / Guardian Phone

Parent / Guardian Email

Parent / Guardian Address

Contact parent or guardian by

phone call

text

Additional Parent (if custody arrangements are in place)

Additional Parent Name

Additional Parent Phone

Additional Parent Email

Additional Parent Address

Contact additional parent or guardian by

phone call

text

Requested Services

Requested services

Speech & Language Pathologist

Occupational Therapist

Psychologist

Counsellor

Mental Health Social Worker

OtherOther

Referrer Information

Referrer First Name *

Referrer Last Name *

Referrer Phone

Referrer Email *

Agency, school, or practice *

Profession/role

Referral Details

Primary reason for referral *

including key presenting key presenting concerns, including severity, degree of urgency and any relevant history, medical/other diagnoses

Details and frequency of support from other service providers

eg RFDS, NWRH, Qld Ed SLP, Qld Health OT, Guidance Officer, HOSES etc

Other relevant information

Please upload any supporting documents (jpg, jpeg, png, doc, pdf)

Maximum file size: 26.21MB

Confirm before submitting

Please tick *

I have discussed this referral with the client or parent/guardian, who has provided verbal or written consent for this referral to be made on their behalf. I also understand that Outback Futures may contact me for further information.

Captcha

If you are human, leave this field blank.

Get in touch

Call or Text: 0417 703 729 (office hours)

Email: info@outbackfutures.org.au

Fax: 07 2145 8025

Post: PO Box 1030, Coorparoo DC, QLD 4151

For 24/7 or crisis support, please call:
Lifeline on 13 11 14
Beyond Blue 1300 22 4636
Kids Help Line 1800 55 1800

In an emergency,
please call 000

We honour and respect the First Nations people of the lands and waterways of our regions. We acknowledge their continuing connection to land, culture, traditions and stories. We honour and respect the Elders past, present and emerging, recognising their cultural heritage, knowledge and relationship to land that support our communities.

Our thanks to Agi Davis Photography and Lisa Alexander Photography for capturing images that reflect the heart and strength of our outback people. Thank you to the friends and clients of Outback Futures who have kindly given us permission to use their photos.

Outback Futures Limited ABN 68 457 355 933

Outback Futures is an Australian charity registered with ACNC.

All donations over $2 are tax-deductible.