Make a referral

Complete the online referral form and a member of our Customer Service team will be in touch to discuss things further.

Fields marked with * are required.

Title

First name *

Last name *

Birthdate *

Is an Interpreter required? *

If Yes, please state the Language

Mobile or Landline *

10 characters remaining

Is this a self-referral?

First name *

Last name *

Your relationship to person you are referring *

Mobile or Landline *

10 characters remaining

Email *

Do you have consent to make this referral? *

Where did you hear about us?

Please provide information about their vision *

32768 characters remaining

What support would they like from Guide Dogs NSW / ACT? *

32768 characters remaining

Please upload relevant documents
Vision report

Discharge Summary

Medical Action Plans

Other Medical information

Does the client receive any funding from any of the following: *

If yes, what is their provider number?

Emma's dream is to get a Guide Dog