top of page

Day Trips & Groups Referrals & Sign Up

DTG Referral form

Thanks for choosing Alacrity Health! Please complete our referral & sign up form below. If you would prefer a form to complete at your own pace or for ongoing referrals, please download the file below. You can email this form to admin@alacrityhealth.com.au or call us on (03)90569191 if you have an questions or need help.

​

Have you signed up for a Day Trip, Group or Annual Event in the past six months?
Have any of your details changed in the last six months? (e.g. support coordinator, emergency/billing contacts)

Services

I am signing up for (select all that apply): Required

details of person completing this form

I am:
CONFIRMATION: I am authorised to agree to service on behalf of the participant signing up for this service

Participant details

These questions are asked to best understand you and the service required. If they are not required to provide service we will list questions as optional - please skip them if you are not comfortable answering them.​

Primary Contact details

Who is the primary contact? (this is the person we contact directly, usually the participant being referred)
Does the participant have an authorised decision maker?

NDIS plan details, funding & service requests

My funding is: Required

Risk details & support plan

Please complete this section if this is your first time signing up to Day Trips & Groups, or if you have not filled this out in the last six months.

i

5_edited.jpg

Referrer details (if not listed above)

Referrer relationship to participant:

Emergency contact

Support coordinator details (if different to referrer)

Thanks for referring to alacrity health! before you finish, we have optional questions to improve this form for you.

I would like to be updated on Alacrity Health's services including community events, day trips, free events/activities and more Required

Thanks for submitting! we will be in touch with you within 48 hours. if this is urgent or you wish to follow up please contact:

admin@alacrityhealth.com.au

(03)90569191

Operating hours

Mon-Fri: 9AM to 5PM

Sat-Sun: Closed

© 2023 Alacrity Health

contact us

  • Facebook
  • Instagram

Mail: admin@alacrityhealth.com.au

Tel: (03)90569191

Follow us on social media!

bottom of page