Child Health Team Referral

Please use the form below to make a referral to the Child Health Team.


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?*

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?*



Child Health Referral Items

Guardian Family Name*

Guardian Given Names*

Guardian Gender*

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?*



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?*

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.
AssessmentCare Plan
Please attach an Assessment and/or a Care Plan if available

Does the client give consent to a referral to Star Health?*

 

 
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