Ookami Kids Referral Form

  • Ookami Kids Referral Form

    Note: This form is used by Ookami Kids to determine whether our services and the child are suited for each other and to perform triage (prioritise care based on the child's needs and our availabilities). The more information you provide, the better we're able to do this.
  •  - -

  • 1. CHILD'S DETAILS

  •  - -
  • Child's Gender Identity
  • Does the child/family identify as Aboriginal or Torres Strait Islander?
  • Does the child attend school / daycare / kinder
  • Please tick all applicable centres
  • Days of attendance
  • Days of attendance
  • Days of attendance

  • Referral Information

  • Has the child received any diagnoses that are relevant to this referral?(for example, disability, neurodivergence, or medical conditions)
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 2. PARENT / CAREGIVER'S DETAILS

  • Parent / Caregiver 1

    Please provide primary contact details. Additional parent/caregiver details will be requested on intake if applicable.

  • Relationship to child
  • Format: (0000) 000-000.

  • Referrer Details (if different from above)

    Please provide contact details of the person completing this form. 

    By completing this section you are confirming that this referral has been placed on behalf of the family, and with their consent.

  • Are you completing this form on behalf of the family?
  • Format: (0000) 000-000.

  • 3. THERAPEUTIC SUPPORTS

  • What type of therapy does the child require at Ookami Kids (please tick all that apply)
  • Does the child require ongoing therapy or an assessment / short-term service?

  • Other Therapy Services Providers

  • Are there any other therapy services currently involved with the child?
  • Add another
  • Add another
  • Has the child previously been engaged with any other therapy service providers?

  • Other Services

  • Are there any other services, relevant to this referral, currently involved with the child? e.g. health, family or community services

  • 4. FUNDING DETAILS

  • Does your child have an NDIS Plan?
  • Does your child have a GP Chronic Condition Management Plan (GPCCMP)
  • Does your child have a Manage Complex Neurodevelopmental Disorders and Eligible Disabilities plan?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 5. PREFERENCES

  • What is your preferred method of communication? Please tick all that apply
  • Do you have a preferred day(s) for services? Please tick all that apply

  • Please note: We will do our best to accommodate your requests for specific dates and times; however, this may not always be possible depending on our therapists' availability.

  • Do you require an interpreter?
  • Do you require the use of an advocate to support you?

  • Please note: If you require the use of an advocate, an Authority to Act as an Advocate form will be provided.

  • Do you have any religious requirements?
  • Do you have any cultural requirements?

  • 6. FINALLY

  • Is there anything else that you would like us to be aware of?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: