Child Development Service Referral Form

  • Child Development Service Referral Form

  • The Child Development Service provides assessment and treatment services for children with developmental delay or difficulties, living in the Perth Metropolitan Area. Referrals can be submitted for children under the age of 16 years.

    Important note:

    • Parent/legal guardian consent to the referral MUST be obtained before submitting this form. Discuss with the parent/legal guardian the need for the referral as well as the information that will be included in the referral.
    • Fields marked with an asterisk (*) are mandatory.
    • Information submitted via this online form is securely stored on a dedicated server in Australia. The information provided will only be shared with Child and Adolescent Health Service staff who are involved in your care.

    To use the save and return function:

    • You must complete the first page (Child's details) and select 'Next'. On the bottom of page 2, you will find a 'Save' button.
    • If you save the form, a link will be sent to your email address.
    • To access your saved form, when you click on the link you will be required to re-enter the child's family name, street address and DOB. If the details do not match exactly, you will be unable to access your draft form.
  • Referrer details - Person completing referral:*
  • Organisation:
  • Referrer Type:*
  • Is the child currently (please tick):*

  • Child's details

  • Date of birth:*
     / /

  • The Child Development Service does not accept referrals for children 16 years and over.

  • *Sex (as on birth certificate):*

  • The Child Development Service provides assessment and treatment services for children with developmental delay or difficulties, living in the Perth Metropolitan Area. Referrals can be submitted for children under the age of 16 years.

    For children located within regional australia including:

    • Gascoyne
    • Goldfields
    • Great Southern
    • Kimberley
    • Mid West
    • Pilbara
    • South West
    • Wheatbelt

    Please visit WA Country Health Service (WACHS)- Referral Information

  • To continue with your saved referral; 

    1. Enter the child's family name.
    2. Enter the street address and date of birth when prompted.
    3. Ensure exact spelling for all entries (e.g. if you entered "Street", do not abbreviate to "St").
    4. If the street address or date of birth fields do not appear and you can see the save button, it means the details entered are incorrect.

  • Child's details

  • The family name entered does NOT match

  • The address entered does NOT match

  • The date of birth entered does NOT match

    • Page 2 

    • For newborn children awaiting a Medicare number, document the primary carer's Medicare details.

    • Is the child an Australian citizen or permanent resident?*
    • Is the child of Aboriginal or Torres Strait Islander origin?*
    • Interpreter required?*

    • Legal guardian details

    • Are any Court Orders in place?*

    • Please attach a copy of the current court orders in the file upload field located towards the bottom of the referral. 

    • Is the child in the care of the Department of Communities - Child Protection Division?*

    • Legal guardian 1

    • Relationship to child:*

    • Child Protection Worker details

      Legal guardian 1
    • Is the residential address the same as child?*

    • For mobile phone numbers, do not include the country code (61).

    • Format: 0000000000.

    • For mobile phone numbers, do not include the country code (61).

    • Does the legal guardian have an email address?*
    • Would you like to add an additional legal guardian?*

    • Legal guardian 2

    • Relationship to child:
    • Is the residential address the same as the child's?
    • Format: 0000000000.

    • For mobile phone numbers, do not include the country code (61).

    • Would you like to add an additional contact?
    • 0/200

    • Reason for referral

    • Please tick all developmental concerns that apply.*

    • Please attach evidence of the date of the original referral to WACHS child development services (e.g. a copy of the original referral).

    • Please provide clinical handover documentation that addresses all iSoBAR components. Where possible, attach the original assessment and subsequent management/intervention reports.

    • 0/1500
    • 0/450
    • 0/500

    • To provide additional supporting information please complete and attach the relevant teacher checklist/s below.

      Occupational Therapy 

      Occupational Therapy — 3 to 4 years

      Occupational Therapy — 4 to 6 years

      Occupational Therapy — 6+ years

      Physiotherapy

      Physiotherapy — 4 to 8 years

      Speech Pathology

      Speech Pathology — English as an additional language

      Speech Pathology — Kindergarten

      Speech Pathology — Pre-primary

      Speech Pathology — Year 1

    • Is the child receiving services in relation to their developmental delay/difficulty through another agency (e.g. NDIS, CAMHS, NGO)?*
    • Would you like to attach supporting documentation to this referral (e.g. Checklists, Private Paediatrician/Allied Health reports, School Psychologist reports)?*
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    • 0/500

    • Referrer details

    • Under the Legal guardian details section of this referral, are you listed as:
    • Format: 0000000000.

    • For mobile phone numbers, do not include the country code (61).

    • Referral consent

    • Please confirm that this referral has been discussed with the legal guardian:

    • I can confirm that this referral has been discussed with    *            * and they have consented to:

      • the referral being made and are aware of the reason for referral 
      • the Child Development Service contacting them 
      • the Child Development Service communicating with me, as the referrer.

    • *Note: When the referral is submitted by anyone other than the child’s legal guardian, the referral cannot be processed without this confirmation.

      If you need to seek consent from the legal guardian, save this form so that you can return to complete it at a later date. 

       

       

    • Important Note: Using autofill can result in incorrect information being submitted. If autofill was used, please carefully review all fields to ensure the details are accurate and relevant to the current referral.

    • Date form completed (dd/mm/yyyy):*
       / /

    • After you submit this referral form using the ‘submit’ button below, you will be prompted to download a copy for your records.

    • For assistance with submitting this referral contact us:

      Phone: 1300 551 827

      Email:  childdevelopmentservice@health.wa.gov.au

      Visit: cahs.health.wa.gov.au/childdevelopment

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