Extended Families - Carer's Rebalance Request Form Logo
  • Carer's Rebalance Wellbeing and Respite Referral Form

  • Welcome to Extended Families Australia's

    Carer's Rebalance Wellbeing and Respite Program

    A Victorian Government Initiative to provide extra support to Victoria's Carers 

    You may save and return to this form at any time, by scrolling to the bottom and clicking 'save'. You'll be emailed a link to the form to complete at a later date.

     

    If you would like more information about Extended Families' services, including the program flier, please check out our website. 

    There you will also find information about other Extended Families' services such as LinC, ExtendABLE Online, Plan Management, Support Coordination, and Volunteer Match. 

     

    If you have any queries or concerns contact Ahysa at ahysa@extendedfamilies.org.au or call her on 0410 923 913

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  • Person Making Referral


  • Note: This referral cannot proceed without informed consent. Informed consent means that the person understands the nature and consequences of the service or program to which they are consenting.

  • As you have selected 'No' to the above question, you have indicated informed consent has not been provided and the referral is unable to proceed.

  • Carer Details

    Details for the person receiving services

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  • Other Contact Details


  • Emergency Contact Details

  • Please include details of someone who can be contacted in the case of an emergency and the main contact person is not available.

  • Support Coordinator Details

  • Should be Empty: