Referral Form | Outback Futures

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)

Please include an email if available as it helps us connect with the client sooner.

Client Email

Client Phone

Client Address

Parent or Guardian Details (16 & under)

Please include an email if available as it helps us connect with the client sooner.

Parent / Guardian Name

Parent / Guardian Email

Parent / Guardian Phone

Parent / Guardian Address

Additional Parent (if custody arrangements are in place)

Please include an email if available as it helps us connect with the client sooner.

Additional Parent Name

Additional Parent Phone

Additional Parent Email

Additional Parent Address

Requested Services

Requested services

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.

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Summary

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Referral form.

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

Client Information

Client's Details (17 & over)

Parent or Guardian Details (16 & under)

Additional Parent (if custody arrangements are in place)

Requested Services

Referrer Information

Referral Details

Confirm before submitting

Summary

Get in touch