REFERRAL TO SOUTH WESTPRESCHOOL FIELD OFFICER SERVICE
10 – 12 Albert Street, Geelong West, 3218 Ph : 52212984 Fax : 5223 1789
Child’s Name
Date of BirthMale Female
Country of BirthPrimary Language
CALD Background
Referred By
Contact Number of referrer
Email Address of referrer
Date of Referral
Please indicate the program this child attends 3 year old group 4 year old group
Is this the child’s first or second year of 4 year old kindergarten?
CENTRE INFORMATION
Name of Centre
Telephone
Address
Degree Qualified Educator(s)
Other Educators
Session times child attends: (Please fill in actual times)
Monday / Tuesday / Wednesday / Thursday / FridayCHILD/FAMILY INFORMATION
Primary Carer(s) name (first and last)
Relationship to Child
Home address
Home phone Post Code
Work/mobile phone
Please list if there are other adults involved in the care of this child that you feel is relevant to this referral. (example Grand Parent(s), Foster Carer, Guardian)
Name(s) (first and last)
Relationship to child
Home address
Home phone Post Code
Work/mobile phone
Name(s) (first and last)
Relationship to child
Home address
Home phone Post Code
Work/mobile
Are there any court orders relating to the powers and responsibilities of the parents in relation to the child or access to the child?
If “Yes” please describe ______
______
CHILD/FAMILY INFORMATION (continued)
Please indicate who the child lives with (Adults, siblings etc)
Please write the name(s) of whom contact/correspondence with the PSFO will be with;
Indicate any languages other than English spoken in the home :
When thinking about your family, is there anything you wish to share that would be important for the PSFO to know?
(for example; Family Background, Culture, Religion, Significant Issues etc)
Family Health Care Card
Carers Allowance
Aboriginal
Torres Strait Islander
SERVICES YOUR CHILD HAS RECEIVED OR IS RECEIVING
Example; Physiotherapist, Dietician, Occupational Therapist, Speech Pathologist, Psychologist, Paediatrician and/or ECIS Intake.
Name / Name of Service / Date last seen or due to be seenFOR THE REFERRER TO COMPLETE
When you think about the child you are referring, please indicate strengths/interests;
When you think about the child you are referring, please indicate what concerns you;
Referrer’s level of concern : (Please Tick)
A Little / Quite / Very / ExtremelyFOR THE PARENT/GUARDIAN TO COMPLETE
When you think about your child, please indicate their strengths/interests;
When you think about your child, please indicate what concerns you;
Parent/Guardian level of concern(please tick)
A Little / Quite / Very / ExtremelyI hereby consent to the referral of my child to the Preschool Field Officer and I give permission for them to contact the above services if any additional information is required. I understand that the Preschool Field Officer Intake service may discuss the information contained in this form with other Early Childhood Intervention services in order to provide the most appropriate service for my child/family.
Parent/Guardian Signature: ______Verbal Consent: Yes/No
Parent/Guardian Name: ______Date: ______
8200 GF 1 – PSFO Referral Form - South West Services Version 2 – 18/02/2016
Form location - F:\Shared\Gateways Policies, Procedures & Forms\Gateways Forms\8000 South West Services \8200 GF PSFO’s