email:
fax: 8346 7333
Referrer’s Information
Service:
Staff Name: / Date of Referral:
Position: / Phone:
Email:
Child’s Information
Name: / Age: / D.O.B:
Male / Female / Diagnosed Disability? Yes/No :
Cultural Identity: / Level of Child’s English:
Current School / Kindy / Childcare:
Carer’s Information
Primary Carer: / Relationship to Child:
Does she/he know about this referral? Yes/No / Level of Carer’s English:
Carer D.O.B: / Carer Phone:
Address:
Please ensure the family has programmed the T4K phone numbers into their mobile(s) so they know who is calling - 8245 8100
Willing to be contacted: / Yes, Best time to call? / No, Liaise via worker above?
Has the child been entered in H2H? Yes/No
Have you called T4K to discuss this referral? Yes/No If yes, who did you speak to?______
Does your service have a case plan in place for the child? Yes/No
If Yes, does the child have multiple needs at present? Yes/No
Is the child attending CAMHS? Yes/No On the CAMHS waiting list? Yes/No
Are you aware of the use of violence in the child’s family? Yes/No
If yes, has a risk assessment been completed? Yes/No Has a safety plan been completed? Yes/No
If yes, what do we need to be aware of to support the safety plan?
Are there any court orders or child protection orders that relate to the child?
Referral Request:Referring for (circle as many as apply)
Group program / 1:1 support and counselling / Unsure
Referral Information:
Please summarise your work with the family (eg purpose & length of involvement) and whether you/your service anticipate working with this family or anyone in the family into the future?
How does the child’s parent think Together 4 Kids may be useful? What are the main concerns?
How do you think Together 4 Kids may be useful?
In this child’s family are you aware of any of the following:
Problem / Yes / Who?When?
Mental health concerns /
Substance abuse /
Suicide risk /
Are there any safety concerns that we need to know about? (e.g. for home visiting, family members)
Is the family engaged with any other support services? Yes/No
If so, please provide details
Do you anticipate the need for a case conference/interagency meeting regarding the child? Yes/No
Do you want any ongoing updates from Together 4 Kids? How?
Admin use only:
DoneH2h referral in client’s CASE PLAN received by Lead Agency
If T4K to become Lead Agency – ADD to H2h
Warm referral completed i.e. phone call to discuss referral
Referring agency & Case Manager details added to T4K Service File
Discussed referral with Team Leader / Clinical Supervisor (if required)
Together 4 Kids Referral Form – updated 301013Page 1 of 3