At the completion of this form, one of our team members will be in contact with your client.

Please note that Sargood on Collaroy provides a service to people living with spinal cord injury.

To be eligible for a stay, a guest must have permanent damage to their spinal cord that is not progressive or palliative.
Sargood on Collaroy is not equipped to support ventilator dependent tetraplegics. (If your client uses an Oxygen Concentrator, please contact us to discuss whether we are able to meet their support requirements)

Client Details

Client's First Name *

Client's Last Name *

Client's e-mail address *

Client's Contact Number *

Preferred check-in dates (if known)

Is there any information you would like to provide about your client?

Referrer Details (the person completing this form)

Your First Name *

Your Last Name *

Your Contact Number *

Your Email Address *

I have been given permission from my client to make this referral and provide their contact details. I have explained to them that a team member from Sargood on Collaroy will contact them. *

Yes

I confirm that my client meets the eligibility criteria to stay at Sargood on Collaroy *

Your Signature *

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