OFFICIAL: Sensitive//Medical in confidence

	

SALHN ALLIED HEALTH/
EARLY CHILDHOOD AND FAMILY SERVICE REFERRAL	

Facility/Site: ……………………………………………………....	

SA Health UR No: ..........................................…………..........

Surname:           <PtSurname>

Given Name:      <PtFirstName>

Second Given Name:   <PtMidName>

  D.O.B: <PtDoB>   Sex/Gender:   <PtSex>	

Referrals can be faxed to Fax: (08) 8384 9727		
Enquiries can be directed to Phone: (08) 8384 9611 
Before referring please consider if this referral may be best served by the National Disability Insurance Scheme (NDIS) see back page.	

PRIORITY CLIENTS	

   Aboriginal or Torres Straight Islander	
	
   Under Guardianship of the Chief Executive	

	

	
   Vulnerable Family	

	
	
REFERRER INFORMATION	
Referrer’s Name:
	<DrName>	Position/Discipline	<DrProviderNo>	
Practice Name / Agency / Department:	<Practice>	Phone :	<UsrPhone>	
Address
	<UsrAddress>	
Email address:	<PracEmail>	Date:	<TodaysDate>	
				
PATIENT DETAILS	
Address:
	<PtAddress>	
Preferred phone:
	<PtPhoneMob>	Alternative phone:	<PtPhoneH>	
Medicare number:
	<PtMCNo>	Expiry date:	<PtMCExpiry>	
Is an interpreter required?	<Interpreter Required>	Language:	<PtLanguage Spoken>	
PARENT/CAREGIVER DETAILS	
Relationship to child:		
Name:		Phone number:		
Email address:		
Address (if different to above):		
Parent/carer signature:		Verbal consent to referral:	
Yes	

No	

 	
Relationship to child:		
Name:
		Phone number:		
Email address:		
Address (if different to above):		
Parent/carer signature:		Verbal consent to referral:	
Yes	

No	

 	
Shared care / custody arrangements:		
Childcare Centre attending:		
Intended Preschool:		Enrolled in Preschool?	
Yes	

No	

	

	

SALHN ALLIED HEALTH/
EARLY CHILDHOOD AND FAMILY SERVICE REFERRAL	

Facility/Site: ……………………………………………………....	
SA Health UR No: ..........................................…………..........

Surname:           <PtSurname>

Given Name:      <PtFirstName>

Second Given Name:   <PtMidName>

  D.O.B: <PtDoB>   Sex/Gender:   <PtSex>	

REFERRAL INFORMATION	
Site Requested:

  GP Plus Marion	

   Noarlunga Village	

   GP Plus Aldinga	

Service Requested:	
	
  Speech Pathology	

   Occupational Therapy	

	
  Psychology (note referrals are not accepted for psychology services alone but must be in 	

  association with developmental delays)	

Please indicate reason for referral:	
	
  Concerns with using words and sentences	

  Unable to follow instructions	

	

	

  Speech (sounds, clarity)	

  Stuttering (repeating sounds and words)	

	

	

  Fussy eating	

  Mealtime behaviour routines	

	

	

  Play skills	

  Child social skills	

	

	

  Sleeping	

  Toileting	

	

	

  Sensory processing	

  Movement skills	

  (Over or under reacts to their environment)	

	

	

	

  Behavioural issues in association with developmental concerns	

	

	

  Parent/child relationship and interaction	

  Other	

	

	

Other allied health or community services involved with this family:	Eg. OT and Physio, FMC Paediatrician, CaFHS Physio, Strong Start

	
Alerts / safety issues:	Eg. Home situation, domestic violence

	
Other relevant information:	Please attached any relevant reports and information including medical history, developmental history, social information, level of vulnerability of the family, current medications, assessment results eg. CaFHS Ages and Stages Questionnaire, Brigance Early Childhood Developmental Inventory).

	
Parent/caregiver days available to attend ongoing therapy	
	
  Monday	

  Tuesday	

  Wednesday	

  Thursday	

  Friday	

Note: Please consider if this client is better served by the NDIS.  If you believe this child has a disability or developmental delays in line with NDIS eligibility please discuss this option with the family.  It may be best to begin the process directly rather than refer to our service where the waiting times can be long.

If possibly eligible please encourage the family to call KUDOS, the South Australian Early Childhood Early Intervention Partner on 1800 931 190 or facilitate the referral yourself.  

OFFICIAL: Sensitive//Medical in confidence