Please Note – If you do not receive a confirmation email within 15 mins of submitting this form, contact us

Participant Details

Contact Details

Key Contacts

Background Information

NDIS Plan Details

Referrer Details

This section is for the Agency or individual making the referral. If this is a self-referral or for a family member, use "Self", "Parent", "Guardian" as the Organisation name and add your own details below.

Please do not put Alliance Rehabilitation's details below.

Information submitted on this form is sent directly to Alliance Rehabilitation and is not stored on this public domain. Further information is available in our Records and Information Management & Privacy & Confidentiality policies.

NDIS Service Agreement

From the 1st July 2023 Alliance Rehabilitation will be utilising a new Service Agreement. This new Service Agreement has been written to be super simple.

Read More

Print Referral

Alternatively you can download one of the forms below, complete and fax to (07) 4771 6971 or email through to reception@alliancerehab.com.au

NDIS

NDIS Referral Form PDF
Download 1.13 MB

NDIS Driving

NDIS Driving Referral PDF
Download 267.75 KB

Online Referral FAQ

As we continually improve our systems, we do occasionally bump into issues. Here are some common issues and questions relating to the online referral form.

Occasionally after pressing submit there will be a notice that “a required field is empty”. There is particular information we require to process your referral. If you scroll up the page, these should be marked in red. Once these are filled in, simply press submit again.

On most browsers, when clicking the date field, there will be a calendar pop-up for you to select the date. If you only see a text field, the format of the date will be either “YYYY-MM-DD” or “DD-MM-YYYY”.

Apologies for the inconvenience – please contact us for support. Alternatively you can use our downloadable referral forms. in pdf, word & rtf format.

Sadly, no. the form functionality is limited and the way it handles information is based upon your browser settings. To save your information from the referral, you will need to cut and paste into your own local text document. The same applies if you are having form issues due to an out of date browser – it is your responsibility to save your information before you refresh or leave this page.

Contact Us Today

To make a booking or to find out more, call 07 4772 1219 or click below for more contact options.

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