“Supporting children during transient times”
Referral Form
email: one: 8245 8190
Eligibility Criteria:
Children aged 0-12yrs within the NAHA Sector
Family must have an active NAHA case manager for the duration of T4K engagement
Referrer’s Information
NAHA Service:
Staff Name: / Date of Referral:
Position: / Phone:
Email:
Is this a re-referral to T4K from your service? Yes  No 
If yes, please indicate when T4K completed the previous therapeutic work: ______
If yes, please ensure information provided includes current information of client situation and concerns
Child’s Information(please complete a separate referral form for each child you are referring)
Name: / Age: / D.O.B: / Gender: F / M
Current School /Kindy /Childcare: / Year/Grade:
Cultural Identity:
Level of Child’s English: (please tick)
 Speaks English language well enough
Interpretor required
Other language spoken at home: ______
Parent/Carer’s Information
Name (1): / D.O.B: / Gender: F / M
Address: / Phone:
Relationship to child: / Lives with child Yes  No 
If “no” does child have contact Yes  No 
Is this person aware of T4K referral
Yes  No  / Is this person willing to be part of the T4K support to the child Yes  No 
Cultural Identity:
Level of English: (please tick)
 Speaks English language well enough
Interpretor required
Other language spoken at home ______
Name (2): / D.O.B: / Gender: F / M
Address: / Phone:
Relationship to child: / Lives with child Yes  No 
If “no” does child have contact Yes  No 
Is this person aware of T4K referral
Yes  No  / Is this person willing to be part of the T4K support to the child Yes  No 
Cultural Identity:
Level of English: (please tick)
 Speaks English language well enough
Interpretor required
Other language spoken at home ______
Administration: Please make sure you have previously discuss this referral with T4K
Child must have an open case plan on H2H in order to be referred into T4K.
Child must have an active NAHA case manager for the duration of T4K engagement.
How long do you anticipate this client will be case managed by your service from the date of this referral? ______
Have you made a H2H services request to T4K at case plan level? Yes  No 
If you are unsure about how T4K can support this child or you need assistance with H2H services request, please feel free to give us call
Reasons for Referral:
Summarise your work with the family (parent/carer(s) case plan, length of support, child’s case plan, etc.)
What are the main concerns for the child at the moment? Who has reported this?
(Please name issues and concerns for child eg.: trauma, increase of emotional distress, experiencing FDV, peer relationship issues, issues around time spent with the other parent, disengagement from school, difficulties in adjustingto home routines, withdrawn, sleeping difficulties, challenging behaviours, etc.)
Are there any factors impacting parenting?
(eg. Trauma, Family court, financial issues, housing, difficulty in seeking appropriate resources, experiencing Family violence, mental health, substance use, social isolation, etc.)
After discussing with parents/carers. What are the areas do you think therapeutic support will be beneficial?( eg. emotional wellbeing, social development and inclusion, family relationships, self-esteem, coping strategies, physical health, etc.)
What are the family strengths?(eg.:extended family and/or friends supports, warmth and positive child-parent/carer relationship, family able to enjoy and have play time together, etc.)
Any other relevant information?
Child Safety and Risk Screening:
Are any of the following risk factors impacting upon the child?
Risk factors / Child
Yes / Parent/ Carer(s)
Yes / Details? Past/Current?
Family and Domestic Violence
Contact/ Handover
Child Safe Conerns
Difficulty meeting daily needs of child
(bathing, food, medication, work)
Substance Use
Previous
Homelessness
Mental Health
Developmental delys / Disability / Diagnosis
Suicide Risk/
Self Harm
Family Court/
Intervention Order (inc named protected persons – i.e. are any children on the IO)
/ Legal Matters
Has a risk assessment been completed? Yes No please provide details:
Has a safety plan been completed? Yes  No please provide details:
Are there any safety issues T4K staff need to be aware of? Yes  No  please provide details:
What other supports are in place for the child and/or the family?
Service / Past / Current / Details?
CAMHS
Dept Child Protection
Parenting Support Program
School/Children’s Centre
Primary Health (mental health care plans, GPs)
Family Safety Framework
Allied Health
(e.g. Occupational Therapy, Speech Therapy)
Other

Thankyou for your referral to Together 4Kids!

Once we have received this referral, we will be in contact with you shortly.

Together 4 Kids Referral Form – updated 21032018Page 1 of 5