QPP Aged Care Navigation Referral

Refer Yourself or Someone to QPP for

Aged Care Navigation and Support

If you know someone, including yourself, who you think is eligible for aged care services and has one or more reasons for requiring intensive support, please complete the below referral and we can put you in touch with the most appropriate care finder program.

If you would prefer to speak with someone, you can call us free from a landline in Queensland on 1800 636 241, or call 07 3013 5555.

Remember, the person must give consent for you to provide any information about them.

For your privacy, all referrals completed via this online form are secure.

Aged Care Navigation Referral Form

"*" indicates required fields

WHO IS THE REFERRAL FOR?

I am completing this Aged Care Navigation referral for…*

Myself

A Friend/Family Member

A Patient or Client

Has the person consented to this referral?*

Yes

QPP is unable to provide services to a person where consent for the referral has not been obtained. Please contact QPP to discuss further on 07 3013 5555 or encourage the person to refer themselves

YOUR DETAILS AS THE REFERRER

Name*

Organisation*

Position*

Contact Phone*

Email*

AGED CARE NAVIGATION PROGRAM ELIGIBILITY

The QPP aged care navigator program is funded by Brisbane North PHN & Brisbane South PHN and delivered in partnership with Communify and Micah Projects. There are strict eligibility requirements for this program. Please indicate details of the person seeking enrolment in the program.

Are you living with HIV?*

Yes

Are they living with HIV?*

Yes

Unsure

Are you/they eligible for Medicare in Australia?*

Yes

Not Sure

I/they identify as*

Aboriginal

Torres Strait Islander

Aboriginal & Torres Strait Islander

Neither

Are you/they located in the Brisbane region?*

The QPP Aged Care Navigation program is currently only available in the Brisbane region.

Yes

Do you/they need assistance with one or more everyday tasks?*

Yes

Are you/they on a low income and homeless, or at risk of being homeless?*

Yes

Are you/they aged 65 years or older?*

Yes

Are you/they aged 50 years or older?*

Yes

Are you/they aged 50 years or older?*

Yes

Are you/they aged 45 years or older?*

Yes

Click to check eligibility

MAY BE ELIGIBLE FOR AGED CARE NAVIGATION PROGRAM

Based on the details provided, you/they may be eligible for the program. Confirmation of eligibility will be conducted by our QPP team upon completion of the referral, and are subject to availability and location.

MAY NOT BE ELIGIBLE FOR AGED CARE NAVIGATION PROGRAM

Based on the details provided, you/they may not currently be eligible for the program. However, please complete the remainder of the referral and our QPP team can assess your/their needs and suggest other support options.

DETAILS OF PERSON SEEKING SUPPORT

Surname*

First Name*

Mobile Phone

Home Phone

Home Address

Street Address City State/Territory Post Code

If you are referring yourself, please make sure to include your email address for email confirmation of your referral.

Can a message be left / contact made?*

To the Email provided

On the home phone provided

On the mobile phone provided

By text to the mobile phone provided

Are there confidentiality concerns?*

Yes

Details

Date of Birth*

Day

Month

Year

Country of Birth*

Do you/they require an Interpreter?*

Yes

What language?

Gender*

Male

Female

Transgender

Non-binary/gender diverse

Other

Do you/they have a personal carer?

Yes

Details

What areas of support can we help with (or other relevant information)?

Support choices

Aged Care Navigation (for older people in the Brisbane region only)

Peer Navigation (for newly diagnosed / HIV health literacy)

Peer Group social activities

Transport

Alcohol & other drugs

Treatment support (access & adherence)

Finances

Mental Health

Housing

Stigma / Discrimination

Legal / Immigration / Visa

Employment

Dental / Oral Health

Other relevant information

Is there anything else that you would like to add or is there anything you think we should know about?

Risk Assessment

Are there any known risks associated with this referral*

Yes

Please Specify

Previous physical assault

Previous verbal aggression

History of dangerous weapons use

History of sexual harassment

If yes, Please specify

Confirmation of HIV status

HIV status can only be confirmed by a client’s GP, HIV Specialist, Sexual health Nurse or POCT

I confirm that the above named client is HIV positive*

Date (Todays Date)

DD slash MM slash YYYY

Signature*

Date of HIV diagnosis

Day

Month

Year

Date of last test

Day

Month

Year

Viral load at last test (optional)

CD4 Count at last test (optional)

For POCT only

Has diagnosis been confirmed?

Yes

Pending

Name

This field is for validation purposes and should be left unchanged.