Child and Family Services

Online Referral Form

**The Child and Family Intake Team are currently experiencing a high volume of referrals. Please be assured your referral will be processed as soon as possible. Thank you for your patience.

Date *

Client Information

Child's First Name *

Child's Surname *

Child's Date of Birth *

Child's gender *

Requested ServicePlease select all that apply

Feeding Clinic
(For children aged 6 months - 6 years where feeding is the PRIMARY concern)

Is the child currently attending a Primary or Secondary School? *

YesNo

Does this child have a current NDIS plan? *

YesNo

Please stop here and complete the NDIS referral form (click link below)https://accesshealthandcommunity.snapforms.com.au/form/accesshc-ndis-referral-form

Referrer Information

Name of person completing this form *

Referrer - Phone number *

Referrer - Position Title *

Referrer - Email address *A copy of this referral will be sent to the above email address after this form is submitted

Referrer - Organisation name and address *

Has verbal consent been obtained from the child's parent/legal guardian to make this referral? *

YesNo

Parent / Carer name *

Interpreter required? *

YesNo

Language

Child's home address *

Home Phone number

Mobile *

Family Email Address (if known)

Is the child of Aboriginal or Torres Strait Islander origin? *

YesNo

Is the child registered with Medicare? *

YesNo

Does the family have refugee or asylum seeker status? *

YesNoUnsure

Referral Information

Please describe reason for referral *

Relevant Medical History

Does the child have a serious or life threatening allergy? *

YesNo

Please describe *

Please list any other services involved

Are there any safety concerns related to this child or family? *

YesNo

Please provide details: *

Is the child known to Orange Door, Child Protection or a FV agency? *

YesNoUnsure

Details:

Has this child been referred to NDIS - Link Health and Community?

YesNo Unsure

Has this child received an approved access letter from NDIS or had a planning meeting?

YesNoUnsure

Any other relevant information

Please attach any relevant documents here

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By clicking Submit below, this form will be forwarded to the Child & Family Intake team. A copy of this form will be emailed to you for your records.

Need assistance? Call 9978 8698

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