Make a Referral for Carer Support

Carer and Family services referrals: A father lovingly cares for his young daughter in a wheelchair as they spend time together in the kitchen, highlighting the importance of family support and caregiving.
Carer and Family services referrals: A father lovingly cares for his young daughter in a wheelchair as they spend time together in the kitchen, highlighting the importance of family support and caregiving.

Refer Yourself or Someone Else to Lifely’s Carer and Family Support Services

Are you a carer looking for support, or do you know someone who is? Use this form to refer yourself or someone else for Lifely’s carer and family support services in Ballarat, Bendigo, Mildura, and surrounding regions.

Whether you need respite, carer programs, emotional support, or guidance navigating available NDIS and disability services for your family member, we’re here to help. Referring is quick and easy—fill out the form below, and our team will be in touch to discuss the best support options.

Who Can Use This Referral Form?

  • Refer yourself if you are a carer needing support.
  • Support coordinators, NDIS planners, and professionals can refer carers and families to Lifely’s programs.

Need more information before making a referral? Call 1300 799 421 or email intake@lifely.org.au, and we’ll be happy to assist!

Carer and Family Services Referral Form

Use this form to connect yourself, a family member, or someone you support with Lifely’s carer and family support services.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

    Carer Information

    Please write your best contact details. If you're filling out the form for someone else, please write their details.
    Name*
    Please enter a number from 0 to 100.
    Address*

      Primary Contact Information

      If the carer is not the main contact, please fill out this section.
      Name

        Support Needs and Schedule

        Describe the type of carer support services you need. We will do our best to accommodate your needs but may need to discuss availability further. If you're filling out the form for someone else, please list their needs and preferences.
        Do you provide unpaid care for someone who has a disability?*
        Unpaid care means looking after a someone with a disability at home without being paid. It often covers tasks like cooking, cleaning, taking them to appointments, doing administrative tasks and helping with daily needs.
        Who do you care for?*
        Please select your relationship to the person with a disability you support. If you support multiple family members, choose "Multiple family members." If the person you support is not listed, select "Other" and provide details. If you are filling out this form for someone else, please provide their details instead.
        Are you their primary carer?
        The primary carer is the person who generally has major daily responsibility for caring and looking after the person with a disability's needs.
        Please select the services you need*
        Please select the services you need. If you're unsure, choose the options that best match your situation. If you're completing this form on behalf of someone else, please outline their support needs and preferences.
        Use this section to share any other important details that may help Lifely provide the best support. This could include specific needs, preferences, communication methods, cultural considerations, or any other relevant information not covered in the form.

          Consents

          Consent for contact*
          Consent*
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