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Child Health Team Referral

To make a referral to ISCH, please fill out the information below.


Referrer Details

Referrer Name*

Referrer Organisation*

Referrer Position*

Referrer Phone*

Referrer Email

Referrer Fax



Client Details

Client Family Name*

Client Given Names*

Client Date Of Birth (dd/mm/yyyy)*

Client Gender*

Client Home Address*

Client Contact Phone Number*

Client Country of Birth*

Is the client of Aboriginal or Torres Straight Islander origin?*
YesNo
Does the client have a refugee status?*
YesNoNot stated/unknown
Does the client require an interpreter?*
YesNo
If yes, please state preferred language

Is the client living in insecure housing?*
YesNo


Child Health Referral Items

Guardian Family Name*

Guardian Given Names*

Guardian Gender*

Guardian Home Address*

Guardian Contact Phone Number*

Can a message be left?*
YesNo
Have the child’s legal guardians provided consent for this referral?
Legal Guardian No.1*
YesNo
Legal Guardian No.2*
YesNo
If not, why not?

Who will attend the appointment and their relationship to the child?*

Are there any other services/agencies involved?*
Pay attention to whether Child Protection, Child FIRST, or Police are involved with the family
YesNo
What is your relationship to the child?*

Who is the legal guardian for the child?*

Are there any court orders relating to children in place?*
YesNo
Are any guardianship and administration orders in place?*
YesNo
Has the child been assessed previously?*
YesNo
What kinder, childcare or school does your child attend?*



Other

Client Medicare Number* (Enter NA if not available)

Please give details of the client's current GP (GP name, Practice name, Address, Phone)*

Does the client hold any of the following concession cards?*
Pension ConcessionDisability SupportHealth Care CardNot stated/unknown
Please outline your reason for referral*

Please tick below if you have an Assessment and/or Care Plan and would be happy for ISCH to contact you to obtain a copy. Alternatively, you can attach them below.
AssessmentCare Plan
Please attach an Assessment and/or a Care Plan if available

Does the client give consent to a referral to Inner South Community Health?*
YesNo


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