Referral Form

We currently are not accepting Psychology referrals

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 *(this is the email address that the confirmation email will be sent to)

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

Are you making this referral on behalf of someone else? *

YesNo

Details of person making this referral

First name

Last name

Phone Number

Email

Please tick this box if you are the Support Coordinator or Caseworker for this child and need to be included in future correspondence and/or attendance at our intake meeting.

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 submitted herewith. *

About Your Child

Primary Diagnosis *

Other information regarding diagnosis

Child's strengths

Child's challenges

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

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Services requested

If 'Assessment Only', please specify

If other, please specify

If you have any preferred times, please provide details *

Please note that if your child attends school, that schools require you to fill in their paperwork to request that Firstchance can visit at the school. Schools will also usually have set dates/times that therapists can attend.

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

The following information will assist Firstchance to support your child and family in the best possible way.

Firstchance embrace culture and diversity, living our values of inclusion, respect, intergrity and commitment.

We believe all children deserve to be supported to be the best person they were born to be.We are all stronger when everyone is included in our community.

Is your child of Aboriginal or Torres Strait Islander Origin *

Child's Country of Birth *

Is your child from a CALD (Culturally and Linguistically Diverse) background? *

What language is spoken at home? *

What is your Child's Cultural Background *

Are there any family customs, religious or cultural practices to be respeced by Firstchance staff? *

Please provide details: *

Do any of the following situations apply to the child:

Foster care/child in non-parental care (e.g. grandparents, kinship) *Child protection / FACS *Parent/carer has disability/health/mental health concerns Family is isolated or without extended family supportSibling(s) with disability

* Please note that for applicants receiving Out Of Home Care, parental responsiblity details will need to be supplied.

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

Summary of 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 *

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