Child and Family Health Referral Form CC-165-01

Children's Mental Health and Wellbeing Referral Form

All Referrals are Confidential

Child and Family Health Department provides a range of services to support the health and wellbeing of children and their families, including expecting parents. Click Here to visit our website for more information.

Please select the preferred Service *

What is your relationship to the client being referred? *

Parent/Guardian Details

Full Name *

Contact No. *

Email Address *

I give consent for this referral to be sent to Gateway Health? *

Referrer Details

Referrer Name *

Referrer Contact No. *

Referrer Email Address *

Organisation Name & Address

Does the referred client give consent for this referral to be sent to Gateway Health? *

YesNo

Does the Parent/Guardian consent for this referral to be sent to Gateway Health? *

YesN/A

Parent/Guardian Name *

Parent/Guardian Contact No. *

Referral Details

Reason for Referral - Please give as much detail as possible *

Are there any Risk or Safety Concerns?

Young Persons Details

First Name *

Last Name *

Contact No. *

Date of Birth *

Email Address

Home Address *

Street address *

City *

State *

Postcode *

Please provide details of preferred safe contact method

Are there any court orders related to the household? *

Child Protection Family Court OrderOther - please specifyNot Applicable

Please provide a brief description

Are there any custody arrangements for the household that may impact participation with our services? *

YesNo

Please provide a brief description

Are there any other services being accessed by the household? *

Please provide further details

Referrer's Signature *

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Referral Date *

Your Signature *

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Referral Date *

Intake Contact Details

Thank you for completing this referral, an Intake Worker will contact the referred client to discuss the next steps regarding this referral.

Thank you for completing this referral, an Intake Worker will contact you to discuss the next steps regarding this referral.

Please indicate a preferred day and time to make contact

For further assistance with this referral please contact the Parenting Team on 0457 279 796.

Where did you hear about this service? *

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