Enquiry Form

Firstchance predominantly suports children with a NDIS plan.

We have limited capacity to support privately funded children

Participant Details

Does the child have a NDIS Plan? *

NDIS Number

How is your plan managed? *

Plan start date

Plan review date

File Upload - Please attach a copy of the current NDIS plan if possible

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Child's First Name *

Last Name *

Preferred name

Street Address (start typing your address in the blank field below. When you see your address appear, click it to select) *

Postcode *

Date of Birth *

Gender *

Name of Playgroup / EarlyLearningCentre / Preschool / School (if attending)

Year due to commence Kindergarten

Or current school grade (e.g. Year 2)

Primary Carer

First Name *

Surname *

Street Address - if different from child's address.

Phone number *

Email address *

Relationship to child *

Please provide the contact details of who to contact in case of an emergency

Name

Phone number

Relationship to child

If any other siblings have previously received, or are currently receiving, services from Firstchance please provide details so that we can do our best when assigning team members to services

Please complete this section if you are NOT** the primary carer of the child

Details of person making this referral

First name

Last name

Phone Number

Email

Please confirm that if this referral is being made by a 3rd party that you have obtained consent from the participant to make the referral and provide Firstchance with the participant's personal and medical details.

Please be aware that if you are completing this form as a 3rd party on behalf of the family the family will receive a copy of your responses sumitted herewith.

Diagnosis

Primary Diagnosis *

Other information regarding diagnosis

File Upload - Please attach a copy of any reports or assessments that tell us about the child's diagnosis or developmental/behavioural concerns. Reports help us to make informed decisions about suitable pathways for support.

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Child's strengths

Child's challenges

Services requested

If Assessment or "Other" please specify

Current services

Are there other professionals or services currently involved in supporting the child/family? *

YesNo

Name

Service provided (e.g. speech therapist, occupational therapist)

Additional Information

Please select any of the following that apply

Foster care/child in non-parental care (e.g. grandparents, kinship) *Child protection / FACS *Parent/carer has disability/health/mental health issuesFamily is isolated or lacking extended family supportSibling(s) with disability

* Please note that for applicants receiving

Out Of Home Care,

parental responsiblity details

will need to be supplied

Details

Are there any court orders or restraints that impact on who can access a service while either parent or carer is in attendance. eg. AVO? *

YesNo

Details *

Please note: If court orders are in place, please bring the original to your first visit.

Additional Information: Please add anything else you would like to share about the child/family.

How did you hear about Firstchance? *

If "other" please provide details: *

Today's date of referral *

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