SLHD Child and Family Health Service Inquiry Form

Emergency Contact Us

SLHD Intranet

SLHD Child and Family Health Service Inquiry Form

SLHD Child and Family Health Service Inquiry Form

* Required Fields. Please submit your application by clicking the 'SUBMIT' button.

Please NOTE: We are not an emergency response or crisis intervention service. If you are worried about a deterioration of your mental or physical health, or that of the person you care for; please see your GP or go straight to the emergency department at your nearest hospital.

In an emergency please call:
Emergency (Ambulance / Fire / Police) 000
Healthdirect 1800 022 222
Poisons Information 131126

If your queries are non-urgent, please proceed to complete the form.

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Required Services

This online form is NOT for child developmental check booking - please call 02 9562 5400 for Child and Family Health Nurses.

Which service/s do you think the child needs the most? *
(tick all that apply)
Click here for more information about the services.

Audiometry (hearing)
Early Childhood Social Work (for parent/carer with children aged 0-3 years)
Child and Family Counselling
Nutrition/Dietetics
Speech pathology
Occupational therapy (OT)
Physiotherapy

Are you? *

Parent/carer
GP
Staff within SLHD
Other external health care worker/ professional like educator

Introduction

The next pages have questions about you and the child you want to refer to Child and Family Health Services. It will take 10-15 minutes to complete the form. If you have documents such as assessment reports, please have them ready to upload.

Upon completion, you can download a copy of the form or receive it via email for your records.

Filling out this form does not mean acceptance into our services. An intake officer may contact you to complete the process within two weeks. If you have any questions with the form, contact us at 02 9562 5400 (Monday to Friday, 8:30am to 4pm).

Can you please confirm if the child or family lives within Sydney Local Health District? *

Yes No

You can check using this Google map link.

We offer services to families living within the Sydney Local Health District boundary.

Important message for GPs:

DO NOT use this form for Community Paediatrics services referral.

Use the Sydney Local Health District HealthLink SmartForms - available through Best Practice, Genie, Medical Director or MyHealthLink Portal.

If you do not have a HealthLink account, sign up for free here.

For further information on SLHD eReferrals, see here.

For referrals to other Child and Family Allied Health services, please continue with the form below.

Referrer First Name *

Referrer Last Name *

Profession *

Provider Number *

Email *

Phone *

Organisation Name *

Organisation Address *

Please ensure client is aware that our intake officer may contact them if further information is required.

Referrer First Name *

Referrer Last Name *

Profession *

Email *

Phone *

Organisation Name *

Organisation Address *

Please ensure client is aware that our intake officer may contact them if further information is required.

Important message for GPs:

DO NOT use this form for Community Paediatrics services referral.

Use the Sydney Local Health District HealthLink SmartForms - available through Best Practice, Genie, Medical Director or MyHealthLink Portal.

If you do not have a HealthLink account, sign up for free here.

For further information on SLHD eReferrals, see here.

For referrals to other Child and Family Allied Health services, please continue with the form below.

Your role and contact details

Referrer First Name *

Referrer Last Name *

Email *

Phone *

Do you work within Child and Family Health Services? *

Yes No

Which department do you work within Sydney Local Health District?

What is your role?

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Child's Details

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Parent/carer's Details

Parent/Carer First Name *

Parent/Carer Last Name *

Date of Birth

MRN (if known)

Relationship to child

What is the relationship?

Gender

Preferred Pronoun

Please specify if you use a different pronoun

Mobile *

Landline (if available)

Address *

Is interpreter required? *

Yes
No
Not Sure

Preferred language *

Parent/Carer of the child is aware and in agreement to the referral? *

Yes
No

Parent/Carer aware child will be placed on waitlist
(if the service has a waitlist) AND encounter on eMR will be created? *

Yes
No

Do you have an alternate contact person if we can’t reach Parent/Carer 1? *
(e.g. another parent/carer, case worker)

Yes
No

First Name *

Last Name *

Relationship to child *

Phone number *

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Documents Upload and Feedback

Please upload any assessment/ report on the child's development or concerns, if you have them.

Note for SLHD staff: For existing client, please upload attachment/s directly onto eMR.

Upload/Attach a file - (max. 6) (pdf):
Please make sure that your attached file should not include any special character
When uploading multiple files they
must be selected at the same time from the same location eg. your Desktop.

Do you have any feedback about this online form? Please feel free to share.

Required!

SLHD Child and Family Health Service Inquiry Form

Required Services

Child's Details

Parent/carer's Details

About the child and the family

About the child's growth and development

What are your concerns?

Documents Upload and Feedback