Children's Therapy Service Referral Form

Details of child

Surname *

First Name *

Address *

Postcode *

Date of birth (dd/mm/yyyy) *

Gender *

Australian Residency Status *

Permanent

Temporary

OtherOther

Current school or child care

Child's Centrelink Number (CRN)

Details of parents(s) / guardian(s)

Name of parent/guardian 1

Parent/guardian 1 address *

Same as child's

Different address

Address

Post code

Name of parent/guardian 2

Parent/guardian 2 address

Same as child's

Different address

Address

Post code

Primary phone number *

Alternate phone number

Email address *

Details of referral

Details of referral diagnosis (if relevant)

Please attach copies of diagnostic reports (if available)

Maximum file size: 10MB

Attach up to three PDF or Word documents. Maximum upload size is 10 Mb.

Type of therapy requested

What interests you in Dog-Assisted Therapy? How do you feel this service could help your child achieve their therapy goals?

Does your child engage in any behaviours that may compromise the safety of our therapy dog?

Yes

No

Please provide details

Available funding

How did you find out about Kites Children’s Therapy? How did you find out about Kites Children’s Therapy?

Contact details of Referrer

Complete this section only if the referrer is not the parent

Name

Agency

Phone number

Email address

Declaration *

I confirm that I have the parent/guardian’s permission to make this referral.

Dog-Assisted Occupational Therapy

Kites Referral Form

Details of child

Details of parents(s) / guardian(s)

Details of referral

Contact details of Referrer