PRE-SCHOOL FIELD OFFICER PROGRAM REFERRAL.

(To be completed in consultation with Parent/Guardian)

  • Please complete all sections of the referral form

NAME OF CHILD:...... ( M/F) DATE OF BIRTH: ...... / ...... /......
NAME OF MOTHER: ...... NAME OF FATHER: ......
Occupation...... Occupation......
Home Ph...... Home Ph......
Work Ph...... Work Ph......
Mob...... Mob......
Email...... Email......
CHILD LIVES WITH: BOTH PARENTS MOTHER FATHER OTHER......
RESIDENTAL ADDRESS: ...... POST CODE:......
POSTAL ADDRESS: ...... POST CODE:......
COUNTRY OF BIRTH: ...... LANGUAGE SPOKEN AT HOME: ......
CULTURAL BACKGROUND...... Australian Aboriginal or Torres Strait Islander: Yes / No
BROTHERS /SISTERS - Name: Date of Birth
...... / ...... / ...... M / F
...... / ...... / ...... M / F
...... / ...... / ...... M / F
REFERRED BY: ...... POSITION:...... DATE: ...... /...... /......
PRESCHOOL INFORMATION.
NAME OF CENTRE:...... PHONE N0: ......
ADDRESS: ...... POST CODE: ......
POSTAL ADDRESS: ...... POST CODE:......
TEACHER: ......
ASSISTANT /CO-WORKER: ......
Has the referral been discussed with the Kindergarten Teacher? (If not referrer) Yes/No
Has the child been referred to: Noah’s Ark Inclusion Support Facilitator Yes/No
Early Childhood Intervention Services, Mallee Family Care Yes/No
Monday / Tuesday / Wednesday / Thursday / Friday
Start Time:
Finish time:
CHILD’S KINDERGARTEN ATTENDANCE TIMES:
Child’s Name:......
OTHER AGENCIES AND SERVICES INVOLVED WITH CHILD / FAMILY
( e.g.: Doctor, Speech Therapist, Child Care, etc - past or present)
......
......
......
REASON FOR REFERRAL
  • PRESENTING CONCERNS ( e.g. physical, language, social, cognitive ,emotional )
......
......
......
  • SOME STRATAGIES YOU HAVE TRIED.
......
......
......
  • ADDITIONAL INFORMATION.
......
......
......
TYPE OF SUPPORT REQUESTED ( PLEASE CIRCLE):
Observation Parent Resources Programming Other
Assessment Support Information Support
PARENT CONSENT:
  • I consent to this referral to the Preschool Field Officer (PSFO).
  • I understand the Pre-School Field Officer will observe my child and support the Preschool staff in assisting with my child’s development and meeting his/her individual needs.
  • I give permission to the Preschool Field Officer to release and or contact other agencies as listed to share information about my son/daughter/child under my guardianship.
Early Childhood Intervention Services..... Paediatrician..... Inclusion Support Facilitator..... Maternal Child Health Nurse..... Other......
  • I understand the PSFO program’s funding body, DEECD, requires that all contact with you is recorded in an electronic client information and case management system known as IRIS. This information is used for statistical purposes and does not include personal information about you.
  • I have received the Mallee Family Care Brochures: “What happens to Information about Me”, “Rightsand Responsibilities” and “Feedback” Yes
Parent / Guardian Name: ......
Parent / Guardian Signature: ...... Date: ...... / ...... /......

I have discussed the information in this referral and “Parent Consent” section with the Parent /Guardian

Referrer’s Signature...... Date......

Email / Mail: 1. Referral form (Completed by referrer) To:Preschool Field Officer

2. PEDS questionnaire (Completed by parent) Mallee Family Care

PO Box 1870, Mildura 3502

or

PSFO use only: Date referral received at office / /

01/02/2015ECDT Policies and Procedures1 of 2