Call [CONFIRM: phone number]

As You Are Care and Counselling

Make a referral

You can refer yourself, or someone you support. Family, carers, support coordinators and plan managers can all send a referral.

It takes about 5 minutes. Most questions are optional. Fill in what you know. We will ask about the rest when we talk.

Questions marked "required" must be filled in. Everything else is optional.

About you
Who are you? (required)

Give a phone number or an email, or both.

How should we contact you?

About the person who needs support

If this referral is for you, you can leave this blank.

This is 9 numbers. You can find it on your NDIS plan. If you do not have it, leave this blank.

How is the NDIS plan managed? (required)

This tells us how we get paid. Choose "Not sure" if you do not know.

So we know if we can travel to you.

What help is wanted?
Which supports are you interested in?

Tick all that apply. You can leave this blank if you are not sure.

For example, goals, good days and times, or communication needs. Please do not include medical records.

We use a quick check to stop spam. You will not need to solve a puzzle. Sometimes it asks you to tick a box.

We use these details only to respond to this referral and to plan supports. We do not sell or share them for marketing. The form is sent to us by email and is not stored on this website. Read our privacy policy.

Demo for review. Not a live website. Forms do not send. Facts marked [CONFIRM] are not yet confirmed.