Individual Referral Form

Individual Referral form

If you require assistance, please contact BUSHkids here

This form works correctly in Chrome, Firefox or Microsoft Edge. If you’re using another browser, please close it now and navigate back to this page.

INDIVIDUAL REFERRAL FORM

Person referring child

Details of CHILD being referred

Note: If the referral is for parenting support only please skip this section

First Name(s)

Surname

Date of Birth

Gender

Address

Postal Address same as Address

Australian Citizen/Permanent Resident?

Visa type (if applicable)

Culturally/Linguistically Diverse Background

Country of birth

Language(s) spoken at home

Do you require an interpreter?

Child identifies as

SIBLINGS receiving BUSHkids services or is an NDIS participant currently

First Name(s)

Surname

Gender

First Name(s)

Surname

Gender

First Name(s)

Surname

Gender

First Name(s)

Surname

Gender

PARENT/LEGAL GUARDIAN details

PARENT/LEGAL GUARDIAN (Primary Contact):

First Name(s)

Surname

Date of Birth

Address

Postal Address same as Address

Relationship to child

Occupation

Preferred method of contact

Phone (Mobile)

Phone (Home)

Phone (Work)

Add Secondary Contact

Other Information

Who does the child live with?

If other please provide details

Does your child attend school/playgroup?

Does your child receive assistance where attending?

Name of School/Childcare/Playgroup (if applicable)

Has your child received a diagnosis of any disorder, disability or syndrome?

If yes, please provide details

Has your child had any previous assessments?

(e.g. speech, child development services)

If yes, please provide details

Other Services

Is your child currently linked with any therapist/s or specialist services?

If yes, please provide more information:

Areas of Concern

Please advise which areas of development you are concerned about:

Language and Communication

(e.g. speech easily understood by others, putting words together to form sentences, understanding what is being said)

Fine Motor Development

(e.g. picking up and manipulating items well, using two hands together, holding a pencil correctly, drawing, using scissors)

Gross Motor Development

(e.g. posture, core strength, crawling, walking, running, jumping and hopping in a coordinated way, climbing, balancing)

Cognitive Development

(e.g. following instructions, playing, puzzles, building with blocks, reading and writing appropriately for age)

Self-Care Skills

(e.g. dressing, toileting, eating, drinking, bathing and sleeping)

Social-Emotional Skills/Behaviour concerns

(e.g. making friends, sharing, taking turns, difficult behaviours, attention and concentration)

Other Information

Is there anything additional about your child's development or your family circumstances that you would like BUSHkids to know?

What support would you like from BUSHkids for your child?

PARENT/LEGAL GUARDIAN CONSENT

Please advise if a Court Order is currently in place

Family Law

Child Safety

Domestic Violence

I give consent to this referral

I consent to further information gathering and assessment processes for my child as detailed in this referral

I give permission for the exchange of information between BUSHkids staff and other professionals relevant to this referral

If applicable, I give permission for BUSHkids to share my personal information with the National Disability Insurance Agency (NDIA) including recording this information in the National Disability Insurance Scheme database.

Referrers Details/Form Completed by

For referrers other than parent/legal guardian:

First Name(s)

Surname

Phone

Verbal consent obtained from the parent/legal guardian for this referral

Verbal consent for further information gathering and assessment processes for the child as detailed in this referral

Verbal consent obtained from the parent/legal guardian for the exchange of information between BUSHkids staff and other professionals relevant to this referral

Verbal consent obtained from the parent/legal guardian for permission to share personal information with the National Disability Insurance Agency (NDIA) including recording this information in the National Disability Insurance Scheme database if applicable to this referral.

Please advise if a Court Order is currently in place (if known)

Family Law

Child Safety

Domestic Violence

Individual Referral Form