Psychological Treatment Service in Residential Aged Care Facilities (RACF) - Register Your Interest Form

Please write your name here. *

What is your phone number? *

What is your relationship with the person that you are registering interest on behalf? *

Have you discussed this form with the residents consent *

YesNo

Does the person you are registering interest for reside in and aged care facility? *

YesNo

What is the name of the person you are registering interest on behalf? *

What is their facility name and phone number? *

Your name *

Your date of birth *

Your facility name *

Your facility address *

Your facility phone number *

Person of contact at the facility

Your phone number *

Reason for Interest *

Date *

Please press the submit button at the bottom of the form for the referral to be returned to the Aged Care Department for processing.

If you require any further information please call the Aged care team at Clear Health Psychology on 08 63784710