Referral Request

About this form

Karumah Inc. provides case management, health navigation, peer connection, and support to people living with HIV in the Newcastle region and surrounds. This referral form can be completed by an individual seeking support (self-referral) or by someone referring another person (such as a health worker, support person, or family member).

We aim to respond to all referral requests within 2 business days. All information provided will remain confidential in accordance with our privacy policy and will be used for it's intended purposes only.

Referral type

I am referring myself

I am referring someone else

Referral Information

First name

Last name

Birthday

Day

Month

Year

A person must be 18 years or older to be eligible for Karumah Inc services.

Phone

Email

Residential postcode or suburb

Is the person being referred living with HIV?

Yes

No

Referrer Information (if you are referring someone else)

First name

Last name

Relationship to the person being referred

Phone number

Organisation (if applicable)

Did the person being referred consent to you completing this form on their behalf?

Yes, consent has been obtained from the person being referred.

No - Please note that we can not proceed with this request without consent.

Self-referral

Declaration

The information provided in this form is accurate and true to the best of my knowledge.