Further information on Carers Victoria’s Privacy Policy is available at Care Recipient 1 Signature of carer Care recipient’s relationship to carer Care recipient’s age Is care recipient living with Or verbal consent obtained by: Care recipient’s postcode Name Care Recipient Condition (Tick all that apply) Date of verbal consent aged (65+ or 50+ for indigenous) Dementia Mail to: Fax to: Person under 65 with a disability Carers Cottage (03) 9396 9595 Carers Victoria Chronic illness PO Box 2204 In need of palliative care FOOTSCRAY VIC 3011 Email: Mental illness For referral enquiries call Carer Advisory Line on 1800 242 636 Specify condition/diagnosis CARE RECIPIENT DETAILS (continued) Care Recipient 2 Care recipient’s relationship to carer: Care recipient’s age: Is care recipient living with Care recipient’s postcode: Care Recipient Condition (Tick all that apply) Frail aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis Signature of person completing form Carer consent: I consent to the information disclosed on this form being provided to Carers Victoria for the purposes of referral and assessment for counselling services and inclusion in de-identified data reporting. I understand that Carers Victoria may contact me in relation to this referral and conduct further assessment.
Care Recipient 1 Care recipient’s relationship to carer Care recipient’s age Is care recipient living with Care recipient’s postcode Care Recipient Condition (Tick all that apply) aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis CARE RECIPIENT DETAILS (continued) Care Recipient 2 Care recipient’s relationship to carer: Care recipient’s age: Is care recipient living with Care recipient’s postcode: Care Recipient Condition (Tick all that apply) Frail aged (65+ or 50+ for indigenous) Dementia Person under 65 with a disability Chronic illness In need of palliative care Mental illness Specify condition/diagnosis Signature of person completing form Carer consent: I consent to the information disclosed on this form being provided to Carers Victoria for the purposes of referral and assessment for counselling services and inclusion in de-identified data reporting. I understand that Carers Victoria may contact me in relation to this referral and conduct further assessment. Further information on Carers Victoria’s Privacy Policy is available at Signature of carer Or verbal consent obtained by: Name Date of verbal consent Mail to: Carers Cottage Carers Victoria PO Box 2204 FOOTSCRAY VIC 3011 Fax to: (03) 9396 9595 Email: For referral enquiries call Carer Advisory Line on 1800 242 636
Referral%20form-Carers%20Cottage.docx