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 (or write not applicable) *

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 (or not applicable) *

Parent/guardian 2 address

Same as child's

Different address

Address

Post code

Primary phone number *

Parent/guardian 2 phone number (or same as primary) *

Email address *

Reason for referral

Please list any diagnoses, disability or areas of concern *

Please attach copies of diagnostic reports (or other relevant information)

Maximum file size: 10MB

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

Swallowing/Choking (Dysphagia)

Are there any difficulties with swallowing (dysphagia), such as choking, coughing, or feeling like food is stuck in the child's throat?

No

Yes, please describe the frequency and severity of these difficultiesYes, please describe the frequency and severity of these difficulties

If yes, are there any management plans or strategies in place to support during a swallowing or choking incident? If yes, please describe (or attach) these plans or strategies in detail.

Positive Behaviour Support

Are there any Positive Behavioural Support (PBS) plans currently in place for the child?

No

Yes, please provide a brief description of the supportsYes, please provide a brief description of the supports

Please upload any relevant documents to the child's swallowing, Behaviour Management Plan or Interim Behaviour Support Plan

Maximum file size: 5MB

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 *

NDIS Participant Number

Name of NDIS Plan Manager

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.

Immediate Capacity

Kites Referral Form