Child and Family Services

Online Referral Form - Lilydale & Belgrave

Does this child have a current NDIS plan? *

YesNo

Are you a Parent/Guardian or a Professional completing this form: *

Parent/Guardian Professional

Other: *

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

YesNo

Date *

Verbal Consent from the child’s Parent / Legal Guardian must be obtained before proceeding with this referral.

Client Information

Child's First Name *

Child's Surname *

Child's Date of Birth *

Child's gender *

Please specify:

Requested Service

Occupational Therapy (preschool ages only)Physiotherapy (0-12 yrs)Speech Pathology (preschool ages only)

Please select all that apply

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

YesNo

Parent / Carer name *

Is this person the child's Legal Guardian? *

YesNo

Relationship to child: *

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? *

YesNoPrefer not to say

Is the child registered with Medicare? *

YesNo

Does the family have refugee or asylum seeker status? *

YesNoUnsure

Does the parent/carer have a current Health Care Card?

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:

Is the family aware of the referral to Child Protection or The Orange Door?

Yes No

If yes, have you gained consent from the family to inform the AccessHC team of CP/TOD involvement/referral?

Yes No

Provide 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

Are there any barriers for you/ for this family to access a similar service privately?

Any other relevant information

Please attach any relevant documents here

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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 *

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? Please contact us on 03 9738 8801

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