Referral Form

Child Details

First Name *

Last Name *

Date of birth *

Gender assigned at birth *

Address: *

Street address *

City *

State *

Postcode *

Does the Child identify as Australian First Nations? *

Name of Daycare/Preschool/School

School year

Primary Parent/Carer Details

First Name *

Last Name *

Date of birth *

Gender *

Does Primary Parent/Carer identify as Australian First Nations? *

Address: *

Street address *

City *

State *

Postcode *

Relationship to Child *

Phone number *

Email *

Parent/Carer 2 Details

First Name

Last Name

Date of birth

Gender

Does Parent/Carer 2 identify as Australian First Nations?

Address:

Street address

City

State

Postcode

Relationship to Child

Phone number

Email

Family Information

Please list name and ages of any other Children or Young People living in the home

Are there any Parenting Orders or Family Court Orders relating to the Child? *

If yes, please attach. Parenting Orders or Family Court Orders

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Medical Information

Please list any diagnosed medical conditions

Does the Child take any regular medication or supplements?

YesNo

If yes, please specify

Name of General Practitioner or Practice

Is the Child accessing other services with health professionals?

YesNo

If yes, please list

Please upload any Health Professionals reports that may be relevant

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Financial and Payment Information

Does the Child have a NDIS plan

If yes, please upload a copy of the Child's NDIS Plan

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If plan managed, please provide details of the Plan Manager

Child's NDIS Number

If you will not be billing the NDIS for this service, please advise who is responsible for the payment of this service?

Separated Families - Partnering as Co-Therapist

This sections only needs to be completed in the event of shared parental responsibility or separated families.

Children need to know that engaging in therapy is supported by both parents. Children need to feel seen, heard, understood, and valued, and as parents, you are best positioned to meet these needs. Therapy with a child requires input, follow-up, and reinforcement from parents and carers. It is imperative that both parents or carers who hold parental responsibility for the child play an active role in supporting the child to attend, participate in therapy and consent to the provision of this service.

If your child is part of a separated family, it is a condition of service that both parents provide consent. By signing below both parents acknowledge that they have read and understood the Separated Families - Parents as Co-Therapists document, and agree to become part of the therapeutic support network for your child.

Both parents are also required to complete the below consent.

Parent 1 Signature

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Parent 2 Signature

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Printed Name

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Printed Name

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Date

Consent

I acknowledge that I have read and understood the ServiceAgreement and understand all of the terms of engagement. I consent to the subject child of this form to access the services of Piece by Piece Play Therapy.

Parent 1 Signature *

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Parent 2 Signature

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Printed Name *

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Printed Name

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Date *

Date