Make a referral

Health professionals  Refer to Access and Total Care Health through SR from your PMS and select Access, or via the contact details below.

Individuals who need support   Refer yourself, or someone you know. We will contact you to help with the next steps.

Are you referring:

Yourself > Go straight to section 2.

Someone else e.g. patient, client, family member > Start with section 1.

Section 1: Referrer Details

Referrer First Name

Referrer Last Name

Referrer Organisation (if you have one)

Referrer Phone

Referrer Email

Relationship to person being referred:

Provide details if you have selected 'Other':

Section 2: Details of person being referred

First Name *

Last Name *

Preferred Name

Date of Birth

Gender

NHI number (if known)

Phone *

Email *

Home address *

Reason for referral

Please provide any other information which may be useful to us

Thank you for sending us this referral. Our team will be in touch within two working days.

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