Extended Families - Carer's Rebalance Request Form

Welcome to Extended Families Australia's

Carer's Rebalance Wellbeing and Respite Program

A Victorian Government Initiative to provide extra support to Victoria's Carers

You may save and return to this form at any time, by scrolling to the bottom and clicking 'save'. You'll be emailed a link to the form to complete at a later date.

If you would like more information about Extended Families' services, including the program flier, please check out our website.

There you will also find information about other Extended Families' services such as LinC, ExtendABLE Online, Plan Management, Support Coordination, and Volunteer Match.

If you have any queries or concerns contact Ahysa at ahysa@extendedfamilies.org.au or call her on 0410 923 913

Current Date

Self referral - The carer is completing their own referralCarer representative (including parent, guardian or other informal person)Support CoordinatorOther professional - ie psychologist, speech pathologist, occupational therapistOther

Note: This referral cannot proceed without informed consent. Informed consent means that the person understands the nature and consequences of the service or program to which they are consenting.

As you have selected 'No' to the above question, you have indicated informed consent has not been provided and the referral is unable to proceed.

Phone callSMSEmailVia representative or guardian

Street Address

Street Address Line 2

SuburbState

Post Code

Yes, they have a disabilityYes, they specialised health / care needsNoOther

YesNoYes, but there is a support person in the household who can assist

Please include details of someone who can be contacted in the case of an emergency and the main contact person is not available.

YesNo, or SC details are not required

Carer's Rebalance Wellbeing and Respite Referral Form

Person Making Referral

Carer Details

Other Contact Details

Emergency Contact Details

Support Coordinator Details