Service Request Form

Self-Referral

Please complete all sections of this request for services at Bobby Goldsmith Foundation.

Important Information Regarding the Referral and Intake Process: Once we receive your service request, we will contact you within two (2) working days to discuss how we can best assist you. You may withdraw your service request at any time. All information recorded on this form will remain confidential.

If you require any additional assistance completing this form (auslan/interpreter services) please reach out to us by calling BGF reception on (02) 9283 8666 or by emailing bgf@bgf.org.au and we'd be more than happy to help you.

Personal Contact Details

Are you living with HIV?

For all non NDIS services, a confirmation of your HIV status from a GP, nurse, social worker etc will be required

Personal Contact First Name

Personal Contact Surname

Personal Contact Date of birth

Personal Contact Phone

Personal Contact Email

Personal Contact Preferred contact method

Personal Contact Residential Address

If no fixed address, please write N/A

Personal Contact State

Service Request Form

Self-Referral

Personal Contact Details

Consent for Referral/Request for Service

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