REFERRAL
Integrated Therapy Service

Act for Kids Integrated Therapy Services (ITS) provide assessment and therapeutic interventions for children, young people and their families who have experienced trauma. Our highly skilled team offers multi-disciplinary services, to support children to overcome their experiences and the challenges arising from their trauma.

Please Note:
Act for Kids ITS services do not provide therapeutic intervention while legal proceedings are ongoing/pending. You are welcome to refer the child or young person once court has been finalised.

This form must be completed by a current stakeholder with the knowledge and consent of the client and client’s legal guardian.

I confirm I have read the and understood Privacy Policy - Act for Kids *

Consent obtained from

Date

If you would like to discuss the referral and eligibility, please contact us.

Please complete all sections of this referral form. Your referral will be formally acknowledged in writing.
Thank you.

DETAILS OF REFERRER

Agency *

Referrer *

Position / Relationship to child *

Address *

Street address *Company name or additional address details

Suburb *

State *

Postcode *

Email address *A copy of the completed referral form will be sent to this address on submission

Phone contact *

Preferred mode of contact *

EmailPhone

DETAILS OF CHILD/YOUNG PERSON BEING REFERRED

Client First Name *

Client Surname *

Client Phone(if applicable)

Address *

Street address *

Suburb *

State *

Postcode *

D.O.B. *

Calculated age of child in yearsAge is calculated based on date of birth entered and is the age at the date of submission.

Identified Gender *

Man or maleWoman or femaleNot specified / preferred not to sayDifferent term (please specify)

Country of birth *

AustraliaNot SpecifiedOther

Primary Language spoken at home *

EnglishNot SpecifiedOther

Disability, impairment or condition: *

YesNoneNot Specified

Provide details of Current Diagnosis *

Please provide details

REFERRAL INFORMATION

Is the child or young person subject to a child protection order? *

YesNoUnknown

Provide details

Is the young person named on an intervention order, domestic violence order or other? *

YesNoUnknown

Provide details

Is there a current custody order in place? *

YesNoUnknown

Provide details

PRIMARY CAREGIVER OF CHILD/ YOUNG PERSON

Name *

Relationship to child *

Phone contact *

Email address *

Street address

City

State

Postcode

LEGAL GUARDIAN OF CHILD/ YOUNG PERSON (if different from above)

Name

Relationship to child

Phone contact

Email address

Street address

City

State

Postcode

EDUCATION / EARLY CHILDHOOD SERVICES

School/Centre

Year level

Contact person

Phone contact

OTHER SERVICES CURRENTLY INVOLVED

Are there any other services involved *

YesNoUnknown

Details

REASON FOR REFERRAL

Please Provide Reason for Referral *

Abuse and/or neglect of the child/young person

Sexual abuse *

YesNoUnknown

Provide details *

Physical abuse *

YesNoUnknown

Provide details *

Emotional abuse *

YesNoUnknown

Provide details *

Neglect *

YesNoUnknown

Provide details *

Domestic & Family Violence *

YesNoUnknown

Provide details *

Risk concerns of child/young person in last 6 months

Current suicidal thoughts *

YesNoUnknown

Provide details *

Current self-harming behaviours *

YesNoUnknown

Provide details *

Aggressive behaviour *

YesNoUnknown

Provide details *

Harmful Sexual Behaviour *

YesNoUnknown

Provide details *

Developmental concerns of child/young person concerned

Emotional regulation difficulties *

YesNoUnknown

Provide details *

Social / emotional concerns *

YesNoUnknown

Provide details *

Intellectual difficulties *

YesNoUnknown

Provide details *

Learning/literacy difficulties *

YesNoUnknown

Provide details *

Speech/language difficulties *

YesNoUnknown

Provide details *

Activities of daily living *

YesNoUnknown

Provide details *

Sensory processing difficulties *

YesNoUnknown

Provide details *

Gross motor difficulties *

YesNoUnknown

Provide details *

Fine motor difficulties *

YesNoUnknown

Provide details *

Hearing/vision previously assessed? *

YesNoUnknown

Provide details *

SUPPORTING DOCUMENTS (IF APPLICABLE)

Consent forms

Permission to exchange information form

Genogram (please provide if known)

Assessments

Current case plan

Court documents

Child Protection history

Other

Provide details

Upload documents

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ADDITIONAL INFORMATION (OPTIONAL)

Any other additional information