Child Health Intervention & Parenting Support
Referral & Registration Form

Referral Details

Complete this section if you are referring someone else or completing it on behalf of someone else.
All Referrals are Confidential

What is your relationship to the person being referred? *

GP/SpecialistParent/CarerSupport WorkerOther

Please Specify

First Name *

Last Name *

Contact Phone Number *

Email Address *

Organisation Name & Address

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

YesNo

If the referred person is under the age of 18, does the parent/carer give consent for this referral? *

YesNoN/A

As the Parent/Carer, do you consent to Gateway Health processing this referral? *

YesNo

As the Parent/Carer do you consent to be contacted in future to evaluate the CHIPS Service? *

YesNo

Eligibility Criteria

Select Clients Local Government/Shire *

WodongaIndigoTowongAlpine

CHIPS is not available outside of the above regions, please contact our team on 0457 279 796 to discuss our other service options.

Select One: *

Child is under 12 years oldChild is over 12 years old

Unfortunately, you are not eligible to receive this service.
Please contact headspace Wodonga or Wangaratta on 1300 332 022 for further information and support options.

Is the child in contact with the child protection system or in out of home care? *

YesNoUnsure

Please provide a brief description

Are there any custody arrangements for the child that may impact upon their participation in this service? *

YesNo

Please provide a brief description

Are both parents required to consent to this service? *

YesNo

*Please ensure both parents have consented to the child attending this service before attending your first appointment.
An additional Consent Form is available here.

Availability *

There is at least one adult family member or carer available to work with the child or young person at the service.There are no adult family members or carers available to work with the child or young person at the service.

Unfortunately, you are not eligible to receive this service. Please contact 0457 279 796 for further information and support options.

Name of Participating Adult *

Contact Number *

Relationship to Child *

Does the Participating Adult require a support person? *

YesNo

Please specify support required

Referral Details

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

What is going well? *

Are there any Safety or Risk Concerns?

Please provide further details

Where did you hear about this service?

Registration Details

Please complete as many details as known, the fields marked with a * are mandatory.

Parent/Carer (Primary Contact Person)

First Name *

Last Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Gender (Sex at Birth) *

Do you identify as LGBTQIA+?

Yes NoPrefer not to say

How would you like us to record your Gender Identity?

Contact Phone Number *

Email Address *

Please Provide Alternative Safe Contact Option

Address *

Street Address *

City *

State *

Postcode *

Indigenous Status *

Mob (If applicable)

Country of Birth *

Refugee Status *

NoYesPrefer not to say

Year Arrived:

Main Language Spoken at Home *

Please Specify Language Preferred

Interpreter Required?

Communication Status *

Please Specify

Source of Income *

Medicare Card NumberType '0' if you do not have a Medicare Card

Expiry Date

Concession Card Holder? *

YesNoUnknown

e.g. Health Care Card, Pension

Card Type

Expiry Date

Do you live with a Disability? *

YesNoUnknown

Please select

Are there any needs/preferences that would assist you

Household Details

Living Arrangements *

Please Specify

Accommodation Setting *

Please Specify

1. Childs Name & Age

Relationship to Child

Living Arrangements

2. Childs Name & Age

Relationship to Child

Living Arrangements

3. Childs Name & Age

Relationship to Child

Living Arrangements

4. Childs Name & Age

Relationship to Child

Living Arrangements

5. Childs Name & Age

Relationship to Child

Living Arrangements

If more than 5 Children, please provide their Names, Ages, Relationship to and Living Arrangements below

Emergency Contact Details

Full Name *

Contact Number *

Relationship to You *

Secondary Registration

Referred Child

First Name *

Last Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Gender (Sex at Birth) *

Does this child identify as LGBTQIA+?

YesNoPrefer not to say

How would you like us to record this Childs Gender Identity?

Does the Child Live at the same address as above Parent? *

YesNoOther

Please provide further details

Address *

Street address *

City *

State *

Postcode *

Indigenous Status *

Mob Name

Country of Birth *

Refugee Status *

NoYesPrefer not to say

Year Arrived:

Main Language Spoken at Home *

Please Specify Language Preferred *

Interpreter Required?

Communication Status *

Please provide further details

Living Arrangements *

Please provide further details

Source of Income *

Medicare Card Number *

Expiry Date

Concession Card Holder? *

YesNoUnknown

e.g. Health Care Card, Pension Card

Card Type *

Expiry Date

Does this Individual live with a Disability? *

YesNoUnknown

Please select

Is the Child accessing NDIS?

YesNo

NDIS Number

Are there any needs/preferences that would assist the Child when attending this service?

Important Client Information

Client's Privacy, Rights & Responsibilities

Gateway Health collect, store, and use your information in accordance with the Australian Privacy Principles and Health Privacy Principles.

Privacy Policy Information is available here
Client Rights and Responsibilities information is available here
Consent to Collect and Use Information form is available here

Acknowledgement and Understanding *

I have read and understood the Gateway Health Privacy Policy *I agree to abide by Gateway Health's Clients Rights and Responsibilities *I am completing this referral on behalf of the client, without the Parent/Guardian present. I understand the Parent/Guardian will be required to return a separate 'Consent to Collect and Use Information Form' (link above) prior to this referral being accepted.

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

Client's Consent to Collect & Use Information

First Name *

Last Name *

Date of Birth *

I agree that Gateway Health can set up and keep a health care record for me *

I agree that all Gateway Health staff involved in my care can access relevant componenets of my health record, to assist in providing the best possible care *

I understand that information may be given to funders of the service, or be used for research and quality assurance activities, subject to confidentiality and privacy provisions of state and federal law *

I agree that my contact details may be shared with the Department of Health and their contractors for quality improvement activities *

I understand that Gateway Health may be required by law to share my information to a third party without my consent for mandatory reporting reasons as outlined in the privacy brochure *

I have read the Gateway Health Privacy Information and understand my right to apply for access to my information *

When needed, I agree to participate in telehealth consultations (including phone and video) using a secure platform, and understand that neither party may record the consultation without prior consent *

YesNo

I agree to share and receive personal health information via electronic submission, e.g.via email or text message, and understand that this may not always be secure *

YesNo

When needed, I agree for photographs or videos to be recorded, stored and used to support my health care; e.g. group activities, home environment, and understand that these will be held securely. *

YesNo

Signature *

Draw signature|Type signatureClear

Person completing this form: *

I am the Parent/CarerI am an authorised person signing on behalf of the person receiving care

Name of authorised person: *

Authorised person relationship to person receiving care: *

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

Intake Contact Details

Thank you for registering your interest in this service, an Intake Worker will call you to discuss the next steps regarding this referral.

Please indicate a preferred day and time for a brief phone call *

Preferred Contact Number *

The same number as providedDifferent to the provided number

Alternate Contact Number

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

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