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

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

Anticipated Number of Attendees

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

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 Huntington's Victoria Education Program is a fee for service program. The cost a session is $250 for up to 10 attendees and an additional $15 per person thereafter. Travel cost will also be included at $54 per hour. For group bookings of 30 people or more please contact us for further details on 03 9818 6333