1. / Referral Received: ____ / ____ / ______
2. / Family / Service ID # : ______
3. / Child ID # :
Service Support Only:
4. / EICM:
5. / Entered into Database:
The purpose of the Referral Form is to collect information in order to assess a child’s eligibility for the SEICT program. It records information about the referrer, family and child, and gains consent to collect and exchange personal information for the purpose of eligibility assessment, evaluation and monitoring. Please be assured that all information that is collected will be treated confidentially and will not be used for any other purposes than what is stated here.
How To Complete This Form
As the person completing this form, if you are: / Please complete sections:
A. / A parent/carer submitting a self-referral / ONE / TWO / THREE / FOUR (Part A)
B. / An early childhood service, school or community organisation seeking support for a child on behalf of the family / ONE / TWO / THREE / FOUR (Part B)
C. / An early childhood service, school or community organisation seeking Service Support Only / ONE / FIVE
Section ONE: Referral Details
1. / Date this form was completed:
2. / Name of person completing this form:
3. / Are you a parent/carer making a self-referral? / Yes
No / Service Name:
4. / Address: / Postcode:
5. / Phone: / Fax:
Email:
Note: If you are an education service seeking Service Support Only – proceed to Section FIVE.
Section TWO: Child Information1. / Firstname: / Surname:
2. / Date of Birth: / 3. / Gender: / Male Female
4. / Is the child Aboriginal or Torres Strait Islander? / Aboriginal
Torres Strait Islander
Both
Neither / 5. / Country
of Birth: / Australia
Other – Please Specify:
6. / Does this child have a diagnosed disability? / No / (go to question 7)
Yes / Please specify:
Who provided the diagnosis?
7. / Does the child attend an educational setting? / No / (go to question 8)
Yes / Name of setting:
Address of setting:
Days of attendance:
Monday Tuesday Wednesday Thursday Friday
8. / Child’s Strengths:
9. / Reason for making this referral to the SEICT:
10. / What are you hoping the SEICT program can help with?
11. / Are there other services already involved with the child/family?
Section THREE: Family Information
1. / Primary Carer / 2. / Other Carer
First Name: / First Name:
Surname: / Surname:
Age Bracket: / 15-24 yrs 25-44 yrs
45-64 yrs 65 yrs and over / Age Bracket: / 15-24 yrs 25-44 yrs
45-64 yrs 65 yrs and over
Gender: / Male Female / Gender: / Male Female
Relationship to Child: / Relationship to Child:
Address: / Address:
(if different to primary carer)
Postcode: / Postcode:
Home Phone: / Home Phone:
Mobile: / Mobile:
Email: / Email:
Primary language / Primary language
Is an interpreter required? / No
Yes – specify language: / Is an interpreter required? / No
Yes – specify language:
Does this person have a diagnosed disabilty, or mental health condition? / Unknown
No
Yes – please give details: / Does this person have a diagnosed disabilty, or mental health condition? / Unknown
No
Yes – please give details:
Please give details of any other relevant information: / Please give details of any other relevant information:
3. / Other children living in the home:
Name / Date of Birth (or Age, if DOB is unknown) / Gender
(please circle) / Does this child have a diagnosed disability or Ongoing High Support Needs? / Has a referral been completed for this child / do you intend to complete a referral for this child?
M / F / Yes No / Yes No
M / F / Yes No / Yes No
M / F / Yes No / Yes No
M / F / Yes No / Yes No
4. / What are the family’s strengths? / 5. / What are the family’s vulnerabilities?
6. / Please give details of any other relevant information you wish to provide about the child/family:
e.g Have you attached any reports to accompany this referral?
Section FOUR: Consent
- If you are a parent/carer submitting a self-referral - Complete Part A
- If you are an early childhood service, school or community
Part A
(For a self-referral completed by a parent or carer) / By giving your consent, you acknowledge that the information provided in this referral is correct, and that you consent to be contacted about the referral for the purposes of assessing your child’s eligiblility for the SEICT program.
Please note: At this time, you are only consenting to being contacted about the referral, this is not an agreement to participate in the program.
I/we confirm that the details provided in this referral are correct.
I/we give consent for SEICT to contact me/us in regards to this referral.
I/we give consent for SEICT to use my/our information for data reporting purposes.
I/we understand that consent can be withdrawn at any time by contacting SEICT staff.
Primary Carer: / Please print name:
Sign: / Date:
Other Carer: / Please print name:
Sign: / Date:
Part B
(For a referral completed on behalf of a family) / Consent acknowledges that the family is aware of this referral being submitted on their behalf and enables SEICT to contact both the family and yourself as the person making this referral. The purpose of contact would be to discuss the referral and if necessary gather further information to assess the child/family’s eligibility for the program.
I confirm that I have obtained VERBAL CONSENT from ______
to complete this referral on the child/family’s behalf.
I confirm that the family has consented to be contacted by SEICT in regards to the referral.
Where possible, gain WRITTEN CONSENT also, by having the parent/carer complete Part A.
I confirm that the details I have provided above are correct. / Name:
Position:
Service/School:
Signed:
Date:
If you are a parent/carer submiting a self-referral, or an early childhood service, school or community organisation submiting a referral on behalf of a family, you have completed the form.
Please refer to Page 6 for details regarding the lodgement of this form.
Section FIVE: Service Support Only (SSO)This section is for an early childhood service, school or community organisation seeking Service Support Only.
Note: If you have completed Sections Two, Three & Four above, you do NOT need to complete this section.
A Service Support Only referral is not related to a specific child; but rather is about requesting in-service support with up-skilling of staff; behaviour management; supporting children with Ongoing High Support Needs in an Inclusive Classroom; whole classroom management; establishing/implementing routines; non-verbal communication tools; etc.
If you are seeking support with a specific child in your care, you need to gain carer consent (and complete sections 2 and 3) for SEICT to be able to discuss a specific child.
Referral Specifics
1. / Who are you seeking support for? / Whole Service/School Staff
A specific room/class / Age group:
Room Leader / Class Teacher:
2. / Why are you seeking Service Support from SEICT?
e.g What are your primary concerns? What is currently happening within your service?
3. / Please give details of any other relevant information you wish to provide about the Service / Staff:
What are the positives? What strategies are working? Do you have any future concerns?
4. / What outcomes are you hoping to achieve through involvement with the SEICT program?
Referral Declaration
5. / I confirm that the details I have provided above are correct.
Name: ______Position: ______
Service/School: ______Date: ______
Lodgement of Form
Any questions concerning the Referral Form can be directed to:
SEICT Project Officer
Phone: 49 03 1700
Once completed, Signed Referral Forms should be emailed, posted or faxed to SEICT via:
SEICT Project Officer
Email:
Mail: P.O Box 103 Cardiff 2285
Fax: 49 03 1760
Once submitted, you can expect to receive notification as to the outcome of the referral within 6 weeks of the completed Referral Form being received by SEICT.
Please be assured that all information collected will be treated confidentially and will be used for SEICT eligibility purposes only.
Samaritans Early Intervention Co-ordination Team | Referral Form - revised JANUARY 2013 Page 1 of 6