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.
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
Private Corporate
For spam and security reasons, this form is optimised for use on the most recent versions of Chrome, Microsoft Edge & Firefox. To check your browser is up-to-date visit http://browser-update.org/update-browser.html#3
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.
We are unable to automatically add a copy of your referral to the confirmation message for security reasons. If the email was to contain any participant information and was to be sent to the wrong address (through a spelling error or mistake) it would constitute a data breach. If you require a copy of the referral contact us to speak to an NDIS coordinator.
Contact Us Today
To make a booking or to find out more, call 07 4772 1219 or click below for more contact options.