SSRG Kids – Paediatric Referral Form - Smart Solutions Rehab Group

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Step 1 of 5 – Your details

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Referral date*

Person completing the form*

Relationship to the child*

1. Child details

Child's full name*

Date of birth*

Gender*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Parent, Nominee or Key Contact name*

Relationship to child*

Phone*

Email*

Does the child identify as Aboriginal or Torres Strait Islander?*

Does the child have any religious or cultural considerations we should be aware of?*

Yes

If yes, please provide details

Does the child require the assistance of an interpreter to access services?*

Yes

If yes, preferred language (if other than English)

Is the child currently known to, or involved with, Child Safety?*

Yes

Unknown

Current legal / care status of the child

Tick all that apply

Subject to Child Safety Intervention or Care Agreement

Subject to a Child Protection Order (Custody or Guardianship to the Chief Executive)

Informal kinship care arrangement (e.g. living with grandparents)

Child Safety details (if applicable)

Child Safety Service Centre (CSSC)

Allocated Case Manager / CSO name

2. Funding

How will the child's therapy services be funded?*

NDIS – Plan managed

NDIS – Self managed

Private / Self-funded

Medicare

Other/unsure

Other/unsure – please specify

Please note that we are currently unable to accept referrals for children whose NDIS funding is Agency Managed.

3. NDIS plan details

NDIS plan number

Plan start date

Plan end date

Billing contact

Invoicing email

Would you like to provide us with a copy of the NDIS plan?

Yes

Upload the NDIS plan

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, heic, Max. file size: 20 MB, Max. files: 5.

PDF, Word or image files, up to 5 files.

Recognised NDIS impairment category

Tick all that apply

Intellectual

Cognitive

Sensory

Neurological

Physical

Psychosocial

Support Coordinator

Support Coordinator name

Agency or organisation

Phone

Is the child under the Office of the Public Guardian?

Yes

4. Referral information

Services required*

Tick all that apply

Occupational Therapy

Speech Pathology

Who referred the child for allied health support?*

Parent/carer

GP or paediatrician

School or early childhood service

Allied health professional

Support coordinator

Other

Reason for referral*

Diagnosis and developmental concerns*

Does the child have any health conditions or medical needs we should be aware of before their first appointment?*

Tick all that apply

Allergies or risk of anaphylaxis

Epilepsy or seizures

Respiratory or cardiac conditions

Mobility or physical handling requirements

Medical equipment or devices

None identified

Other

Other – please specify

Does the child have an emergency management plan, medical action plan or specific medical precautions?*

Yes – copy to be attached

Yes – please discuss with me

Upload the plan

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, heic, Max. file size: 20 MB, Max. files: 5.

PDF, Word or image files, up to 5 files.

Please briefly describe any relevant medical needs, risks or precautions

5. Current professionals and supports

Is the child currently receiving support from any of the following professionals?*

Tick all that apply

Occupational Therapist

Speech Pathologist

Physiotherapist

Psychologist

Paediatrician

Behaviour Support Practitioner

None currently

Other

Other – please specify

Please provide the names and services of any professionals currently involved in the child's care (if known)

Please attach any reports from previous or current professionals

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, heic, Max. file size: 20 MB, Max. files: 5.

PDF, Word or image files, up to 5 files.

6. Behaviour, sensory needs and emotional regulation

Are there any situations or responses we should be aware of to help the child remain safe and supported during appointments?*

Tick all that apply

May leave a room or area unexpectedly

May become distressed or overwhelmed in unfamiliar environments

May hurt themselves when distressed

May hurt others when distressed

Sensitive to noise, lighting, touch or other sensory input

Difficulty with transitions or changes in routine

No concerns identified

Other

Other – please specify

Are there any known situations, environments or experiences the child finds particularly distressing or overwhelming?*

What helps the child feel safe, comfortable or supported when they are upset or overwhelmed?*

Is there an existing Positive Behaviour Support Plan?*

Yes (please attach a copy)

Under development

Upload the Positive Behaviour Support Plan

Drop files here or

Accepted file types: pdf, doc, docx, jpg, jpeg, png, heic, Max. file size: 20 MB, Max. files: 5.

PDF, Word or image files, up to 5 files.

7. Environment and appointment preferences

Who is likely to attend appointments with the child?*

Location for appointments*

Tick all that apply

Home

SSRG Clinic

School

Other

Other – please specify

8. Environmental risk screening

Does the client consent to a home visit?*

Yes

Are all occupiers agreeable to a home visit?*

Yes

Please provide names of anyone who will be present during the visit*

Please note that for our clinician’s safety during your consultation we require that the premises be smoke free throughout the appointment, that all pets are restrained, and that visitors are kept to a minimum.

Safety requirements*

Please tick this box to confirm you can meet these safety requirements during your appointment.*

Please provide details of anything else the clinician needs to know before accessing the premises*

For example, information about parking or access to the property

Have there been any recent acts of abuse, aggression or violence on the premises?*

Yes

Does anyone residing at the premises receive services from agencies such as Mental Health, Alcohol and Other Drugs?*

Yes

Does anyone residing at the premises have any medical or psychiatric conditions of which our clinician should be aware?*

Yes

Does anyone residing at the premises have a forensic history, a current criminal record, conviction, or supervision order?*

Yes

Are there people who should NOT attend the premises while your clinician is present?*

Yes

Does anyone residing at the premises have a current contagious condition (e.g. HIV, Hepatitis, Staph)?*

Yes

Is anyone residing at the premises currently taking cytotoxic medications? (usually prescribed for cancer)*

Yes

9. Marketing information

How did you hear about Smart Solutions Rehab Group?*

Tick all that apply

GP or medical practice

Other health professional

Support Coordinator or Plan Manager

Family or friend

Google or other online search

Social media

SSRG website

Previously used SSRG services

Other

Other – please specify

Thank you for completing this form. We look forward to meeting you and your child.

We recognise that every child and family is different. Your therapist will work with you to understand your child’s strengths, interests, support needs and goals.

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