24 Hour 7 Day a Week Online Referral Service

Do you have a client or patient that needs to be placed into care or requires private case management?

We will respond to your request within 24 hours. If you require a more urgent response we will be in contact within 2 hours.

Please fill out the following form:

1. Please select one of the following options: *

Quote for a service
Please Proceed with care and keep me informed
Please Contact Family about haaa services & how haaa can help
How can haaa help me with this case?

2. Your details:

Organisation/Your name: *
How do you prefer to be contacted: * (e.g. phone, email, mail, etc...)
Relationship/Association with the person your are enquiring or referring: *

3. Referral details:

Is this case urgent? *		No Yes and reason: (We will respond within 2 hour or call 1300 784 781 now)

Client/Patient's Name:
Where is this person currently: *
Does this person have a Guardian? *		No Yes and who:
Does this person have a power of attorney? *		No Yes and who: Not known

Best persons to talk to regarding this case (please provide at least one):

Person 1: *				Best contact phone/email: *
Why This Person: *
Person 2:				Best contact phone/email:
Why This Person:
Person 3:				Best contact phone/email:
Why This Person:

Case Brief: *
Ideal Outcome: *

Thank you for your online enquiry!