Refer Myself To Access Support

Referral for QPP Support

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

This form is for you to complete if you would like access a particular service/s from QPP. If however you are looking for information, you can send us an email, send us a message through our contact page, via our chat function (bottom right of page), by email or call us toll free from Queensland on 1800 636 241 or on 07 3013 5555.

If you are experiencing a medical emergency, call 000.

If your issue or enquiry is urgent, please phone 1800 636 241 or 07 3013 5555 for immediate assistance.

Self Referral Form

"*" indicates required fields

Your Details (Please include at least one way to contact you)

Todays date

Surname*

First Name*

Mobile Phone

Home Phone

Can a message be left*

On your home phone

On your mobile phone

By text to your mobile phone

Home Address

Do you have any concerns about confidentiality in regards to your HIV status?*

Yes

I am not living with HIV

Please specify

Date of Birth

Country of Birth*

Medicare Eligibility*

Eligible

Ineligible

Interpreter required*

Yes

Language

Gender*

Male

Female

Transgender

Non-binary/gender diverse

Other

You identify as*

Aboriginal

Torres Strait Islander

Aboriginal & Torres Strait Islander

Neither

Do you have a carer?

Yes

Details

What type of support would you like to receive

Support Types

Other relevant information

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

How did you know about QPP self referral?*

Once you click submit referral a helpful team member from QPP will be in contact with you

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