PAEDIATRIC REFERRAL TO THE NEUROSCIENCES UNIT
Confidential – Please print clearly
REFERRER’S DETAILS:Referrer’s Name: / Position Title:
Agency Name: / Telephone:
Agency Address:
Email Address:
CLIENT’S DETAILS:
Client’s Name:
Is child known by any other name?
Date of Birth: / Gender:
Home Address:
Current School: / Year Level:
Aboriginal or Torres Strait Islander: / Y / N / Interpreter Required? / Y / N
Language Other Than English:
RELEVANT FAMILY INFORMATION
Best Contact Person:
Relationship to Client: / Parent / Guardian / Carer
Home Phone Number: / Mobile Number:
Email: (required)
Aboriginal or Torres Strait Islander: / Y / N / Interpreter Required? / Y / N
Language Other Than English:
Nuclear Family / Single Parent / Blended Family / CPFS Involvement
Comments:
Legal Guardian:
Family aware of referral? / Y / N / Consent form signed by family? * / Y / N
* Consent form available on our website, or by phoning 08 9347 6464
PRESENTING PROBLEMS: (include duration, frequency, previous history)Are you aware of any psycho-emotional or behavioural factors that may affect a lengthy testing session? (e.g. anxiety, agitation, aggressive behaviours, physical limitations etc.) / Y / N
Do you believe the child will be comfortable separating from his/her parents/carers during the assessment (3 - 4 hours)? / Y / N
Are there any outstanding medico/legal issues? / Y / N
REASON FOR REFERRAL AND GOALS FOR THE NEUROPSYCHOLOGICAL ASSESSMENT:
(Please make referral questions as specific as possible)
PAST RELEVANT NEUROLOGICAL/MEDICAL/PSYCHOLOGICAL HISTORY:
Has this child been assessed by a psychologist or speech pathologist before? (If yes, please provide details of previous testing completed and attach any relevant reports). / Y / N
CURRENT MEDICATIONSAND MEDICAL INVESTIGATIONS: (Please attach any available investigative reports).
Current medication dose and length of use:
Results of any CT, MRI, EEG:
AGENCY/HEALTH PERSONNEL INVOLVEMENT:
Agency Name / Contact Person / Telephone / Agency aware of referral? / Current involvement?
Y / N / Y / N
Y / N / Y / N
Y / N / Y / N
Waitlists apply.
To discuss the suitability of this referral, please phone the Duty Clinician on 08 9347 6464.
Signed by Referrer: / Date:Referrals can be faxed to 08 9385 6813, or emailed to:
Paediatric NSU Referral form (v2) FINAL 27.10.2017 P1/2