For referrals and intakes please contact:
03 9525 1300
Please use the form below to make a referral to the Child Health Team.
Client Family Name*
Client Given Names*
Client Date Of Birth (dd/mm/yyyy)*
Client Home Address*
Client Contact Phone Number*
Client Country of Birth*
Is the client of Aboriginal or Torres Straight Islander origin?*
Does the client have a refugee status?*
Does the client require an interpreter?*
If yes, please state preferred language
Is the client living in insecure housing?*
Guardian Family Name*
Guardian Given Names*
Guardian Home Address*
Guardian Contact Phone Number*
Can a message be left?*
Have the child’s legal guardians provided consent for this referral?
Legal Guardian No.1*
Legal Guardian No.2*
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
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?*
Are any guardianship and administration orders in place?*
Has the child been assessed previously?*
What kinder, childcare or school does your child attend?*
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 Star Health to contact you to obtain a copy. Alternatively, you can attach them below.
Please attach an Assessment and/or a Care Plan if available
Does the client give consent to a referral to Star Health?*
Please prove you are human by selecting the Star.