Referral Form

Accessing Geronimo OT services is easy - simply complete the referral form below and our Intake Worker will be in touch to complete the paperwork and get you started.

Please be aware that our current service areas are:
- City of Greater Geelong
- City of Melton (Wait List)
- Hume City Council (Wait List)
- Maribyrnong City Council, and
- City of Hobsons Bay

AdobeStock_83523677.jpeg

PARTICIPANT DETAILS:

Date Of Birth:
 

 
 




Disability/Diagnosis:

Aboriginal/Torres Strait Islander:

School/Placement:

DETAILS OF PERSON MAKING REFERRAL:
 
Referral Made By: Relationship:
Referral Email: Referral Phone: