Request for support form

PalAssist provides palliative care information and compassionate support to those dealing with a life limiting illness and those who care for them.

We aim to work with health professionals in providing palliative care information and support to their clients.

When you submit a request, we will make two attempts to contact your client within 5 business days, after such time, if unsuccessful, a PalAssist team member will leave a message (if able) and encourage the client to contact us.

Please complete the form below and a member of the PalAssist team will respond to your request

Referrer details

The request form is to be completed by a health professional on behalf of, and with the consent of, the client.

A first name is required
A last name is required
An email is required
A phone number is required
A location is required
A location is required

Patient details

By submitting this form you are agreeing to the privacy collection statement here.