E-Referral | WorkFocus Australia

E-Referral

Referral to WorkFocus Australia is simple with e-referral.

Simply select the type of assistance you require, completing the mandatory fields and send to WorkFocus Australia. Our Referrals Coordinator will take care of the rest.

The fields marked with * are required fields.

Personal Details

Surname *
First Name *
Title *
Date of Birth (dd/mm/yyyy)*
Street Address *
Suburb *
Post Code: *
Region: *
Phone (Work) *
Phone (Mobile)
Phone (Home)
Occupation
Is English Second Language?

Employer

Company
Contact
Address
Phone
Fax
Email

Insurer

Company
Contact
Address
Claim No.
Phone
Email

Injury Details

Date of Injury (dd/mm/yyyy)
Injury

Nominated Treating Doctor

Name
Address
Phone
Fax

Specialised Services Required (please tick) *

Return to work for same employer
Return to work for new employer
Specific Services
Consultancy

Comments

Referral Details

Title
Referred by *
Phone Number *
Select one of the following * Referred by their employer
Referred by their insurer
Referred by their doctor