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

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

If you are completing this form on behalf of someone else, please remember that the person must give consent for you to provide any information about them. 

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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Consent
I am completing this form on behalf of:  *
If you are completing this form on behalf of someone else, has the other person given consent for you to contact QC on their behalf?  
Clear selection
If you are completing this form on behalf of someone else, what is your name?
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 describes your gender?  *
Required
Is your gender different to what was presumed for you at birth?  *
Were you born with an intersex variation? 
An intersex variation can include variations in chromosomes, gonads, sex hormones, or genitals that do not fit the binary definition of male or female. 
 *
Which of the following best describes your sexuality?  *
Required
Do you 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:
Please include suburb, state, and post code.
What is your preferred contact method? *
Required
Do you/they have confidentiality concerns about us contacting them/you?
I.e: Will this person be concerned about other people knowing that they are engaging with QC/our services?
 *
Do you require assistance with managing appointments and providing informed consent? 
 *
If you answered 'yes' to the above, please provide contact details for the nominated support person. *
Do you require an interpreter?  *
If you require an interpreter and would like QC to arrange one for you, what is your preferred language? 
You will not have to pay for us to arrange an interpreter for you. 
Program Eligibility
QC's Aged Care Navigation program is currently only available to people living in the Brisbane Region. If this is not you, please continue with this form as we may be able to provide support in other ways. 
Are you eligible for Medicare in Australia?  *
What is your residential suburb? *
Do you need assistance with one or more everyday tasks? *
Are you:
Select as many answers as appropriate.
 *
Required
Do you have a carer? *
Additional Services
QC offers numerous services that aim to improve the physical, social, and emotional wellbeing of Lesbian, Bisexual, Gay, Transgender, Intersex, Queer, Sistergirl and Brotherboy people and communities. Are you interested in linking in with any of the following programs? Please select as many as you like. 
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