WE ACCEPT REFERRALS FORM

General Practitioners, Allied Health Professionals, Community-based Agencies, Legal Representatives, and Other Agencies

Each referral is assessed by our Intake and Clinical Team. If they consider the patient is suitable for the residential program, the patient will be contacted and given further details about the intake process.

Referral Form

"*" indicates required fields

For General Practitioners, Allied Health Professionals, Community-based Agencies, Legal Representatives and Other Agencies

Step 1: Patient’s Details

The patient is aware of the referral and agrees to be contacted by HARP Private Rehab

FIRST NAME*

LAST NAME*

D.O.B*

YOUR EMAIL ADDRESS*

YOUR PHONE NUMBER*

REASON FOR REFERRAL*

DETAIL DIAGNOSTIC CONSIDERATIONS*

Step 2: Referring Doctor’s Details

PREFIX*

FIRST NAME*

LAST NAME*

SPECIALITY*

PHONE*

YOUR EMAIL ADDRESS*

By clicking Make A Referral, you agree to let our Intake and Clinical Team use the information provided to manage the referral and also accept our Terms and Privacy Policy.

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General Practitioners, Allied Health Professionals, Community-based Agencies, Legal Representatives, and Other Agencies

Referral Form

Step 1: Patient’s Details

Step 2: Referring Doctor’s Details

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