Parenting Programs
Referral & Registration Form

All referrals are confidential

Our Parenting Programs provide both individual parenting support and group-based parent education programs and information sessions to parents and carers of children aged from 0 to 18 years. Individual parenting support is available all year and can be tailored to suit the needs of the parent. Our group programs run each school term and can vary from term to term to find out more about these programs please select from the links below.
Programs we offer include:
-     Mother Goose
-     Tuning in to Kids
-     Tuning in to Teens
-     Triple P (Positive Parenting Service)
-     Dads Tuning into Kids
-     Stepping Stones (based on Triple P’s strategies)

Please Select Preferred Services: *

Parenting Education (Face to Face)Positive Parenting Telephone Service (PPTS)Parenting Groups (e.g. Tuning into Kids)

Referral Details

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

What is your relationship to the person being referred? *

Self GP/SpecialistOther

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? *

YesNoN/A

If you are over the age of 18, do you consent to Gateway Health processing your referral? *

YesNoN/A

If you are under the age of 18, does your parent/carer give consent for Gateway Health to process this referral? *

YesNoN/A

I understand the referral will not be processed without the clients consent, if you would like to discuss this further contact our Parenting Team on 0457 279 796.

Reason for Referral

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

Which Program/s is there an interest in? *

Are there any Safety or Risk Concerns? *

Are there any current services/people supporting the client? *

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.

First Name *

Last Name *

Preferred Name

Preferred Pronouns

Date of Birth *

Gender (Sex at Birth) *

Do you identify as LGBTQIA+? *

YesNoPrefer 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 Number *Type '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

Living with a Disability? *

YesNoUnknown

Please specify any needs/preferences that would assist you

Household Details

Living Arrangements *

Please Specify

Accommodation Setting *

Please Specify

1. Childs Name & Age