Referral to Preschool Field Officer

Please email to PSFO@brimbank.vic.gov.au

To be completed by Teacher/ Educator/Referring Agency

Date of Referral _________________

__/__/__

Child’s details

First name:

Date of birth:

Child usually called

Family name:

Gender:

Male [ ] Female [ ] Other [ ] Prefer not to disclose [ ]

Address:

Suburb:

Postcode:

Language Spoken:

Country of birth:

Parent/Carer details

Parent/Carer 1

Parent/Carer 2

Title:

Mr [ ] Mrs [ ] Ms [ ] Miss [ ] Dr [ ] (please tick)

First name:

Family name:

Relationship to child:

Language Spoken:

Country of birth:

Do you need an interpreter:

Yes [ ] No [ ]

Home Number:

Mobile Number:

Email:

Title:

Mr [ ] Mrs [ ] Ms [ ] Miss [ ] Dr [ ] (please tick)

First name:

Family name:

Relationship to child:

Language Spoken:

Country of birth:

Do you need an interpreter:

Yes [ ] No [ ]

Home Number:

Mobile Number:

Email:

Early Start Kindergarten Yes [ ] No [ ]

Is the child of Aboriginal descent? Yes [ ] No [ ]

Is the child of Torres Strait Islander descent? Yes [ ] No [ ]

Is the child up to date with Maternal Child Health Checks? Yes [ ] No [ ]

Were any issues raised at the MCH check? Yes [ ] No [ ] Name of MCH Nurse …………………….

Name of Kindergarten ____________________________________________________

3 Year Old Program [ ] Funded 4 Year Old Kindergarten [ ]

SESSION TIMES AND DAYS AT SERVICE

	Monday	Tuesday	Wednesday	Thursday	Friday
AM
PM

Reason for Referral/ Request:

☐ Behaviour	☐ Communication	☐ Nutrition/Diet	☐ Self Help/Care Skills
☐ Play Skills	☐ Developmental	☐ Physical	☐ Social/Emotional

☐ School Readiness

☐ Other (please specify):

SUPPORT REQUESTED FROM PSFO

☐ Observations

☐ KIS Application Support

☐ Reflective Discussion

☐ Referral Pathways

☐ Resourcing

☐ Strategies for Child

☐ Group Strategies to Enhance Inclusion

☐ Other (please specify):

Significant information to share:

(Family context, birth history, Refugee background, awaiting diagnosis, developmental concerns…)

Is the child accessing NDIS? Yes [ ] No [ ]

Other Professionals/Agencies involved:

(e.g. Kindergarten, Early Education & Care program, Community Health - IPC, Therapist, Paediatrician, Family Support Agencies)

Name of Service	Contact Name, position and number (if available)

Privacy and Confidentiality

The personal information collected through this form will be used by Brimbank City Council for the purpose of enabling the Preschool Field Officer Program to have the information required to best support the Kindergarten service. We may disclose this personal information to relevant stakeholders involved in the program, such as Kindergarten Educators, other professionals/agencies listed on this form with consent. The data will be kept confidential and identifying information will not be disclosed for any other purpose, unless required by law.

Parent/ Guardian signatures

I declare that I have read and understood the above procedure and agree for this PSFO referral to be considered under these terms.

Parent/Guardian Name

Signature: ___________________________________ Date ______________________

Verbal Consent (in case where written consent is not available)

[ ] I have discussed this referral with the parent/guardian. I am satisfied they understand the proposed referral and I have their informed verbal consent.

Referred by:

Name of service:

Telephone No:

Email:

Referrer Name

Signature: ___________________________________ Date ______________________