Education Program Referral Form

Name of Referrer

Address

Organisation (if applicable)

Email Address

Contact Number

Who will be Attending: Who will be Attending: Medical Nursing Allied Health Direct Care Staff Family Members General Community Mainstream Organisations (ie. NDIS, Justice System, Community Services etc.) Other (Please Specify)

Other...

Is this request in relation to a community member you are working with at the moment? Is this request in relation to a community member you are working with at the moment? Yes No

Name of Community Member

Has the person consented to this referral? Has the person consented to this referral? Yes No

Is the cost being claimed through the individual's NDIS plan? Is the cost being claimed through the individual's NDIS plan? Yes No

If yes, please provide NDIS Number, Full Name, DOB, Email, Address

Preferred Mode of Delivery? Preferred Mode of Delivery? Standard Delivery Tailored Delivery

In-person or virtual session? In-person or virtual session? In-person Virtual

Number of Attendees

Reason for Referral (Please provide any details that can assist us to meet your education needs)

Topics of Interest: Topics of Interest: Effects of Huntington’s Disease on General Functioning The Value of Medical and Allied Health Input External Mainstream Services Available for the Huntington’s Disease Community Impact of Huntington’s Disease on Family and Lifestyle Rights of the Person with Huntington’s Disease Understanding Your Duty of Care Prepare for the Future Genetic Testing and Living with Your Results Family Planning Options How to Proactively Live with Huntington’s Disease The Role of Huntington’s Victoria Other (Please Specify)

Other...

How did you hear about our services?

Terms and Conditions Terms and Conditions By submitting this form I understand that I have provided my informed consent to this referral and that a member of Huntington's Victoria will be in contact to discuss this referral further. I understand that the Huntington's Victoria Education Service is a fee-for-service program. The cost per session is $250.25 + GST for up to 12 attendees, and $350.35 + GST for more than 12 attendees. Travel fees apply at a rate of $1 per kilometre. For group bookings of more than 24 attendees, please contact us for a quote on (03) 9818 6333.