Child & Family Health Services Referral

All Referrals are Confidential

Our Child & Family Health Programs offer a variety of services designed to support the health and wellbeing of individuals, families, expecting parents, and children. Click here to visit our website for more information.

Please select your preferred service *

What is your relationship to the person being referred? *

Please specify

Referrer Details

Full Name *

Contact Phone Number *

Email Address *

Organisation Name & Address

Does the person you are making the referral for give consent for this referral? *

Will anyone under the age of 15 years be participating in service? *

If yes, does the Primary Parent/Guardian give consent for this referral? *

Parent/Guardian Details

Full Name (Primary Contact) *

Contact Number *

Email Address *

Full Name (Secondary Contact)

Contact Number

Email Address

Are there any 'Parenting Arrangements' in place that may impact upon participation in this service? *

Please provide a brief description

Referral Details

Referral Date

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

Do you have any of the following concerns?

Feelings & Behaviours (Managing emotions and conduct)Family Relationships (Connections with parents and relatives)Friendships (Making friends and peer interactions)Self-Esteem & Confidence (Feeling valued, at ease, and expressive)Education & Learning (School engagement, focus, and play)Physical Health (Diet, sleep, movement, and development)Housing Stability (Secure, comfortable, and stable living conditions)Safety (Protection at home and in public)

Please provide further details

Are there any Risk or Safety Concerns?

Where did you hear about this service?

Registration Form

Client Details

Your Details

Have you been a client at Gateway Health before? *

Has the referred person received a service at Gateway Health before? *

Full Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Contact Phone Number *

Email Address *

Home Address *

Street Address *

City *

State *

Postcode *

Please provide an alternative Safe Contact Option *

Sex *

Sex assigned at Birth *

Do you identify as part of the LGBTIQA+ community?

Gender Identity *

How would you like us to record your Gender Identity?

First Nations Status *

Name of Mob

Country of Birth *

Nationality *

Main Language Used *

Is an Interpreter Required? *

Did you come to Australia as a refugee or asylum seeker? *

Year Arrived

Main Communication Used *

Please specify

Main Source of Income

Concession Card Type *

Do you have a Medicare Card? *

Please list any known medical conditions, allergies, or sensitivities we should be aware of:

Living with a Disability?

Please provide further details

NDIS Number

Are there any needs/preferences that would assist you with accessing this service?

Household Details

Living Arrangements *

Please specify

Accommodation Setting *

Please specify

How many children are in the household?

Please provide child's/children's age and gender

Emergency Contact Details

Full Name

Contact Number

Relationship to You

Relationship to Client

YesNo

Registration Form

Additional Family Member #1

Relationship to Previous Family Member *

Has this Additional Family Member been to Gateway Health before? *

Full Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Contact Phone Number *

Email Address *

Does this person you live at the same address as the previous family member? *

Home Address *

Street address *

City *

State *

Postcode *

Please provide any further details

Please provide an alternative Safe Contact Option

Sex *

Sex assigned at Birth *

Does this person Identify as part of the LGBTQIA+ community?

Gender Identity *

How would this person like us to record their Gender Identity?

First Nations Status *

Mob Name

Country of Birth *

Nationality *

Main Language Used *

Is an Interpreter Required? *

Did this person come to Australia as a refugee or asylum seeker? *

Year Arrived

Main Communication Used *

Please specify

Main Source of Income

Concession Card Type *

Does this person have a Medicare Card? *

Please list any known medical conditions, allergies, or sensitivities we should be aware of:

Does this person live with a Disability?

Please provide further details

NDIS Number

Are there any needs/preferences that would assist this person with accessing this service?

Household Details

Living Arrangements *

Please specify

Accommodation Setting *

Please specify

Emergency Contact Details

Full Name *

Contact Number *

Relationship to You *

Relationship to Client *

YesNo

Registration Form

Additional Family Member #2

Relationship to Previous Family Member *

Has this Additional Family Member been to Gateway Health before? *

Full Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Contact Phone Number *

Email Address *

Does this person live at the same address as the previous family member? *

Home Address *

Street address *

City *

State *

Postcode *

Please provide any further details

Please provide an alternative Safe contact option

Sex *

Sex Assigned at Birth *

Does this person identify as part of the LGBTQIA+ community?

Gender Identity *

How would this person like us to record their Gender Identity?

First Nations Status *

Mob Name

Country of Birth *

Nationality *

Main Language Used *

Is an Interpreter required? *

Did this person come to Australia as a refugee or asylum seeker? *

Year Arrived

Main Communication Used *

Please specify

Main Source of Income

Concession Card Type *

Does this person have a Medicare Card? *

Does this person live with a disability?

Please provide further details

NDIS Number

Please list any known medical conditions, allergies, or sensitivities we should be aware of:

Are there any needs/preferences that would assist this person with accessing this service?

Household Details

Living Arrangements *

Please specify

Accommodation Setting *

Please specify