Enquire

Childs Name*

Childs First NameChilds Last Name

Child’s gender*

DOB*

Parents/Carer’s Name*

Parents/Carer’s First NameParents/Carer’s Last Name

Contact Phone Number*

Email*

example@example.com

What therapies is your child currently receiving*

What therapy are you interested in?*

Are there any current Child Protection matters involving your child or family? (i.e. physical abuse, violence, neglect, sexualised behaviours between siblings or against minors, exposure to or involvement in domestic/family violence, etc...)*

If Yes, Please provide a short description of concern and supports in place.

Has your child ever engaged in behaviours (ie through actions or words) expressing that they want to be dead? This includes suicide notes/messages or impulsive behaviours which may result in death or serious injury.*

Has your child ever engaged in any self-injurious behaviours (i.e. head banging, biting themselves, cutting, burning, including impulsive behaviours which may result in death or serious injury etc) OR expressed through words that they would like to do so? *

Has your child ever disclosed, thoughts, actions or words, intent to cause serious harm to others?*

You have indicated some level of suicide, self-harm or harm to others risk for this referral. Head 2 Toe Kids and Family Health is NOT a crisis support service. We have substantial wait times for services and are not the appropriate service to adequately support you or your family if there are active suicide, self-harm or risk to others-based concerns. If you or your child have ANY current concerns around suicide, self-harm, or risk of harm to others please utilise the appropriate crisis support options:

Call 000 and ask for ambulance
Present to your local Emergency Department
Contact the NSW Mental Health line to support with triaging concerns; they are available 24 hours/ 7 weeks on 1800 011 511

If you or your loved one require crisis counselling or emotional support, please utilise the appropriate services:

Lifeline: 13 11 14 | www.lifeline.org.au (24/7; crisis counselling for adults and teens via phone or chat); 13 92 76 (13 YARN) for Lifeline-trained Aboriginal and Torres Strait Islander Crisis Support specifically
Kids Helpline: 1800 55 1800 |www.kidshelpline.com.au(24/7; crisis counselling for child via phone or chat)
QLife: https://www.twenty10.org.au/get-support/lets-talk/chat-online/ (counselling after 3pm to midnight specifically for LGBTIQ+ populations)
Parent Line NSW: 1300 1300 52; counselling support for parents/ parenting issues (9am-9pm, Mon-Fri; 4pm- 9pm on weekends)

If you believe that your referral does NOT have active suicide, self-harm, risk to others concerns despite answering ‘yes’ to our risk-based questions and a potential long wait-time may be appropriate in your case, please contact Head 2 Toe Kids and Family Health on (02) 8894 1013 and ask to speak to our Intakes Team to proceed further with this referral. We are NOT able to accept this referral through this automated online system and clinical consultation is required before we can add your child’s information to our waitlist.

Has your child had an assessment in the past 12 months?*

Does your Child have a diagnosis? If so, what is the diagnosis?*

Preferred availability*

Funding type*

Brief description of reasons for therapy*

How did you hear about us?

By submitting this Intake form for Head 2 Toe Kids and Family Health, I acknowledge:*

All information provided is accurate to the best of my knowledgeThis referral will be reviewed at time of allocation and may be declined if it is not suited to our serviceThere may likely be a waiting period until I am allocated to a clinician for ongoing support or services (wait times are subject to change, depending on the availability of the clinicians and their varying caseloads)There are NO suicide, self-harm, or risk to others for this referral