Aged Care Navigation Referral Form
If you have a patient or client who has questions about accessing Aged Care services in the greater Brisbane area, please complete this form so we can connect them with someone who will be able to provide them with the support and assistance they require. 

If you would prefer to speak with someone over the phone, please get in touch with us on 07 3017 1777. 

QC recognises the importance of upholding the privacy of our service users; as such, all referrals submitted via this online form are secure. For more information on QC's Privacy Policy, please visit our website which you can access via this link: https://www.qc.org.au/privacy
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I am completing this form on behalf of:  *
Consent
Has the person whom you are referring provided consent for this referral to be made?
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Personal and Contact Details of Person Seeking Support
Full name: *
Date of Birth: *
Pronouns:
IE: He/him, she/her, they/them, etc. 
Which of the following best describes the person's gender? *
Required
Is their gender different to what was presumed for them at birth? *
Were they born with an intersex variation? 
An intersex variation can include variations in chromosomes, gonads, sex hormones, or genitals that do not fit the binary definitions of male or female.
 *
Which of the following describes their sexuality? Select all that apply.  *
Required
Do they identify as Aboriginal, Torres Strait Islander, or South Sea Islander? Please select all that apply.  *
Required
Best contact number: *
Secondary contact number: 
Email address: *
Residential address:
Please include suburb, state, and post code. 
 *
Postal address (if different to residential address):
Please include suburb, state, and post code.
What is their preferred contact method?
Are there confidentiality concerns about this person being contacted by QC?
I.e: Will this person be concerned about other people knowing that they are engaging with QC/our services?
 *
Does this person require assistance with managing appointments and providing informed consent?  *
If you answered 'yes' to the above, please provide contact details for the person's nominated support person.
Do they require an interpreter?  *
If you answered 'Yes' to the above, what is their preferred language? QC will arrange a free translator. 
Program Eligibility
Are they eligible for Medicare in Australia?  *
What is their residential suburb?
QC's Aged Care Navigation program is currently only available to people living in the Brisbane Region. If the person lives outside of Brisbane, please continue with this form as we may be able to provide support in other ways. 
 *
Do they need assistance with one or more everyday tasks? *
Are they:
Select as many answers as appropriate:
 *
Required
Do they have a carer? *
Risk Assessment
Are there any known risks associated with this referral? If yes, please provide as much detail as possible.  *
Referrer Information
Full name: *
What is your relationship to the service user?  *
What is the best way for us to contact you if required? *
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