Health Justice Partnership Referral

We ask you to fill out this form so we can work out how best to support your patient with their legal problem.

The information you provide here will be confidentially and safely saved in our system. Our administrative staff, paralegals and lawyers will use this information to contact your patient, make an appointment with a lawyer and work out how we can assist them.

We aim to get in touch with your patient within 5 business days of you submitting this form.

Referral date

Referrer first name

Referrer last name

Referrer Organisation Name

Referrer Contact Number

Referrer email address

Referrer occupation and department

What is your patient's first name?

What is your patient's last name?

What is your patient's date of birth?

What is the patient's best contact number?

What is the patient's email address?

Is it safe for us to call the patient on the phone number provided?

Is it safe for us to leave the patient a voicemail?

Is it safe for us to send the patient an SMS?

Is it safe for us to email the patient?

How does your patient identify in relation to their gender?

If your patient prefers, please describe their identity here

What are your patient's pronouns?

What is the first name of the other party in your patient's legal matter?

What is the last name of the other party in your patient's legal matter?

What is the date of birth of the other party in your patient's legal matter?

Which of the following factors relate to your patient

Please press and hold 'ctrl' to select multiple options

Gestation at date of referral

Estimated due date of patient

What does your patient need legal help with?

Please press and hold 'ctrl' to select multiple options

Is there any other relevant information you can provide about your patient?