Referral Form - Saltbush Balnarring Beach

Online Referral Form

Saltbush, Balnarring Beach is a not-for-profit charitable organisation. We provide holidays, retreats and programs to people experiencing hardship. We also welcome community and school groups. Most guests are referred by community service organisations, funded by the NDIS, or are connected to Saltbush through a hospital or school. This ensures that our guests are genuinely in need. Saltbush is not equipped to provide intensive support to guests. Guests must be accompanied by a carer if they require day to day support. Saltbush is a holiday service and does not provide crisis accommmodation.

This form can be completed by community service organisations, hospital, schools, and individuals.

Referrers Details

Name*

Name of your organisation

Your role

Contact Phone Number/s:*

Contact Email:*

Person/Family/Group Referral

Reason for Referral (tick all that apply to the person/people being referred):

Physical Disability
Mental Ill Health
Illness
Grief and Loss
Carer (for children with special needs, disability or ill health)
Single Parent family
Carer (Grandparent, Kinship or Foster Carer)

Carer (for partner or parent)
Recovery from Family Violence
Refugee or Asylum Seeker
Financial Need
Community Group
School Group
Other

Additional Information/Details:

Who will be funding this stay?

Fully Funded by Agency/Organisation/School/Hospital
Fully Funded by NDIS
Self Funded by guest
Combination

Does the guest have a Health Care Card?

Yes
No
Unknown

This referral is for:

An Independent Stay
A School Holiday Program
A Carers Retreat
Using the Nano Community Space

When would you like to stay?

Next Available

When would you like to stay?

How did you hear about Saltbush?

If you’re ready to provide guest details, please complete the information here:

Guest 1

Name

Address

Street Address

Phone

DOB

Emergency Contact Name

Emergency Contact Phone

Guest 2