Hawthorn Community House Supported Playgroup

This is a free program by referral only from Maternal and Child Health or your healthcare provider.
If you are interested in enrolling, fill out this form and we will contact you shortly.

Referrer Information

Referrer Name: *

Referrer Position: *

Parent/Carer Details

First Name *

Last Name *

Preferred Name

Title:

Pronouns

She/HerHe/HimThey/Them

Date of Birth *

Email Address *

Phone Number *

Gender *

MaleFemaleOtherPrefer not to say

Country of Birth *

Interpreter Required *

YesNo

Home Address *

Street address *

Suburb *

State *

Postcode *

Do you have family in the country who provide you and your family with support? *

Do you have friends you connect with on a regular basis? *

Have you accessed or are you accessing support from an Enhanced Maternal and Child Health Nurse for your child? *

Do you have concerns for your child's development? If yes, provide details: *

Has your child been referred to NDIS? *

Do you access any other services to support your wellbeing or parenting? If yes, provide details: *

Do you have any safety concerns for you or your family? If yes, provide details: *

Are you or your immediate family homeless, or at risk of homelessness? *

Are you a non-permanent resident? *

YesNo

Do you have a healthcare card? *

YesNo

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

YesNo

Does the family have refugee or asylum seeker status? *

YesNo

Child Details

First Name *

Last Name *

Preferred Name

Date of Birth *

Country of Birth *

Gender *

MaleFemaleOtherPrefer not to say

Do you have another child? *

YesNo

Child Details (2)

First Name *

Last Name *

Preferred Name

Date of Birth *

Country of Birth *

Gender *

MaleFemaleOtherPrefer not to say

Yes, I give consent to have information about me collected and shared as outlined in our privacy policy. *

I have been given a copy of the information handbook that includes our 'Rights and Responsibilities' and 'Privacy Statement.' *