Extended Families - Carer's Rebalance Request 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 Keely at keely.hay@extendedfamilies.org.au or call her on 0452 236 850

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Relationship to the referred person:*

Self referral - The carer is completing their own referralCarer representative (including parent, guardian or other informal person)Support CoordinatorOther professional - ie psychologist, speech pathologist, occupational therapist

Name of person filling this form:*

First NameLast Name

Referrer mobile phone number:

Referrer email:

example@example.com

Preferred contact method:

Phone callSMSEmail

Referrer organisation or business name:

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.

Has consent been obtained to fill this form?*

YesNo

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's Rebalance Wellbeing and Respite Referral Form

Person Making Referral

Carer Details

Other Contact Details

Emergency Contact Details

Support Coordinator Details