Client Signup

Plan, Support & Living Details

Mobility status

Plan dates (start and end)

Plan management

Is the participant engaged with Public Trustee and Guardian?

Yes No

Sensory impairment (if applicable)

Visual impairment Hearing impairment Sensory impairment Autism spectrum disorder (ASD) Other

Psychological / special needs (if applicable)

Living conditions

Working status

Note: Equal Care NSW collects this information to assess supports and deliver services safely. Please only provide information you are authorised to share.

Referrer (Referee) Details

Date of Referral

Full Name *

Organisation Name

Referee Phone Number

Referee Email *

Your Relationship to the Client

By submitting this form, you confirm you have authority/consent to provide the participant’s information to Equal Care NSW for the purpose of assessing and providing supports.

This form is protected by reCAPTCHA.

Equal Care NSW — Referral Form

Additional Links

Helpful Links

Contact Us

Equal Care NSW — Referral Form

Demo Title