Make a Referral : Khaya Project

On Call

Mail Us

Client Name or Initials

Date of Birth

Gender

Diagnosis

Contact Address

Postcode

Telephone Number

Current Placement

Case Manager

Reason for Referral

Person making referral (if different from above)

Funding authority

Type of accomodation required

Preferred region to stay

Description of client diagnosis

Does the client require a gender-specific environment?

Does the person have physical disabilities/requirements?

If yes, describe the physical disabilities/requirements:

Approximate staffing levels required:

Is a responsible medical officer required?

Are wake nights required?

Please add any other information:

Additional Documents

Enter verification code

This information will be stored and processed for the purpose of this enquiry and will not be shared, transferred or sold without consent. Privacy

I understand and agree

When uploading documents please ensure total file size is under 10mb