CHIPS Referral Form

All referrals are confidential

Unfortunately you are not eligible to receive this service. Please contact the CHIPS team for further information and support options.

Select one: *

My child is under 12 years oldMy child is 12 years or older

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.

Select one: *

There is at least one adult family member or carer available to work with the child or young person at the serviceThere 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 the CHIPS team for further information and support options.

Person completing the form (Referrer)

Last Name *

First Name *

Role (eg teacher, parent/carer) *

Organisation:

Email Address *

Contact phone number: *

Parent / Guardian Consent to Referral

Services and Schools - Please complete with adult of child referred

I give consent for a referral to be sent through to CHIPS *

I give consent to be contacted in the future to evaluate the service

I require a support person

Support required *

Personal Information (Child)

Last Name *

First Name *

Preferred Name

Date of Birth *

Unfortunately you are not eligible to receive this service. Please contact the CHIPS team for further information and support options.

Address *

Street address *

City *

State *

Postcode *

Country of Birth *

Main language spoken at home *

EnglishOther

Please specify language:

Interpreter required

School attendance *

Child younger than 5 not attending schoolDaycare / Kindergarten / Pre-schoolPrimary SchoolChild over 5 not attending school

Refugee status

NoYes

Year arrived:

Does the child or their parent live with a disability?

NoYesPrefer not to say

Please provide further specification

Is the child accessing NDIS?

NoYes

NDIS number:

Is the child in contact with the child protection system?

NoYesPrefer not to say

Please provide further specification

Other supports or people involved with the child

Are there any custody arrangements for your child that may impact upon their participation in the CHIPS program or any child protection orders? *

NoYes

Are both parents required to consent to this service? *

NoYes

Please ensure both parents have consented to the child attending this service before attending your appointment

Parent / Guardian Information

Primary Parent / Guardian

Last Name *

First Name *

Date of Birth *

Address *

Street address *

City *

State *

Postcode *

Contact Phone Number *

Email Address *

Relationship to Child *

Country of Birth

Source of Income

Employed / self employedGovernment benefit / PensionNo incomePrefer not to say

Health Care / Concession Card *

NoYes

Card type (eg Health Care Card, Aged Pension, DVA)

Willing to participate in sessions with child *

YesNo

Name of adult participating with child *

contact phone number *

Relationship to child *

Other Parent / Guardian

Last Name

First Name

Date of Birth

Address - if different from above

Street address

City

State

Postcode

Contact Phone Number

Email Address

Relationship to Child

Country of Birth

Source of Income

Employed / self employedGovernment benefit / PensionNo incomePrefer not to say

Health Care / Concession Card

NoYes

Card type (eg Health Care Card, Aged Pension, DVA)

Willing to participate in sessions with child

YesNo

Other Children in Family

Name

Age

Gender

Living at same address

YesNo

Reason for Referral

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

What is going well? *

Privacy Information

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

Please complete the Consent to Collect Information form here

Please contact us on xxxx if you prefer to complete the Consent to Collect Information form with the assistance of a clinician

I have read and understood the Gateway Health Privacy Policy *

I agree to abide by Gateway Health Client Rights and Responsibilities *

Appointment Booking

Complete if you would like to book an appointment now. Otherwise we will be in touch to book an appointment with you.

Select a Service

Preferred contact phone number *

Save and Complete Later