Referral to Early Childhood Partners

Early Childhood Approach (ECA)

Referral to Early Childhood Partners

Please use this form to provide Each with information about a child aged under 6 with developmental concerns/delays or for a child who has a diagnosed disability up to 9 years of age.

Please do not complete this form if;

your child has a current NDIS plan or if you are re-engaging (please refer to portal for your Early Years Specialist’s contact details and contact them directly)
you have a meeting scheduled with an Early Years Specialist (please refer to your meeting confirmation email for your Early Years Specialist’s contact details and contact them directly)

For children over 9 years old, please contact your Local Area Coordinator: https://www.ndis.gov.au/contact/locations

This form may be completed by;

a family member or carer, with or without the assistance of a professional.
a professional working with the family or carer (e.g. paediatrician, allied health workers, educators, case workers) with consent. Please note that legal guardian consent is required to progress a referral.

You are about to submit an online enquiry form where your details will be sent via email to our intake team. Alternatively, if you have any concerns about the security of your information being sent via email, you can make an enquiry by phone via our central enquiries number on 1300 003 224.

Proceed to submit this form via email *

YesNo

Please contact our central enquires number on 1300 003 224

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Child's Details

“Please use names as per legal identification documents e.g. birth certificate”

Child's First Name *

Middle Name

Surname *

Child's Gender *

Preferred Pronoun

Date of Birth *

Child's Age Years

Child's Age Months

Is the child of

Aboriginal originTorres Strait Islander originBoth Aboriginal & Torres Strait Islander originNeither

Country of birth *

Is the child an Australian Citizen? *

YesNo

Are you a permanent resident?

YesNo

Please advise visa details

Do you have an immediate family member who is applying for the NDIS or is already a participant?

YesNo

If yes, please advise the name of your family member

If yes, please advise their NDIS number

Who does the child live with?

Custody or court orders - Is there an existing parenting, custody or guardianship arrangement for the child? *

YesNo

(If 'yes' please attach them to this form when submitting)

Family or Carer Details

A Family Engagement and Assessment Coordinator will call you to talk about your child’s development, concerns you have, and your current support systems. This information will help us to understand your child’s needs so we can help you to connect you with the right supports and services.

Family or Carer 1 details

Family/Carer First Name *

Family/Carer Middle Name

Family/Carer Surname *

Date of Birth *

Please describe your gender *

Preferred Pronoun

Relationship to Child

If other, please specify

Home Address *

Street address *

Suburb *

State *

Postcode *

Contact Number *

Email

Preferred Contact Method

What is your preferred day for us to contact you?

What is the preferred time for us to contact you?

Please let us know if you will be unavailable at any specific timeframe over the next 28 days? e.g. travelling overseas

What languages are spoken at home?

Do you require an interpreter?

If yes, please advise the language

Family or Carer 2 details

Family/Carer First Name

Family/Carer Middle Name

Family/Carer Surname

Date of Birth

Please describe your gender

Preferred Pronoun

Relationship to Child

Other, please specify

Address

Street

Suburb

State

Postcode

Contact Number

Email

Preferred Contact Method

What is your preferred day for us to contact you?

What is the preferred time for us to contact you?

Please let us know if you will be unavailable at any specific timeframe over the next 28 days? e.g. travelling overseas

What languages are spoken at home?

Do you require an interpreter?

If yes, please advise language

Diagnosis / Developmental Concerns

To help us understand more about your child’s needs, please provide the following information.

Does your child have a formal diagnosis?

YesNo

“Please Note: if your child is 6 years of age and older, they will need to have a formal diagnosis of a permanent lifelong impairment.”

If yes, please specify:

If no, does your child have developmental delay or do you have concerns about their development?

YesNo

Additional information (for example: Diagnosis, recent hospitalisation, starting school soon, etc.)

Services

Please list all supports you are currently engaging with (e.g. education, medical, community services, recreational)

Contact details (including organisation name)(eg. school, childcare, therapists, paediatricians, etc.)

Consent: Does the parent, carer, guardian or child representative give permission for EACH, the EC Partner, to contact the above listed professional or service provider and share the child’s information to better understand their circumstances? *

YesNo

Main Concerns

How does your child manage to move around and interact in their environment?(e.g. walking/crawling, sitting, rolling, using their hands, coordination, using mobility aids etc)

How does your child learn and play?(e.g. remembering and practicing new skills, playing games and with others, pretend/role play)

How does your child communicate with you?(e.g. full sentences, combining 2-3 words, hand gestures, body language, understanding what’s being said to them)

How does your child express feelings and emotions, and how do they relate to others within the home or community?(e.g. emotional regulation, interactions with others, how they cope with change)

Does your child need help with daily activities and routines?(e.g. feeding, bathing, dressing, toileting)

File Attachments

Please do not upload the following documents:

Evidence of identity document. Your Early Specialist will collect identity documents when they meet with you.
Password protected documents. The NDIS are no longer able to upload these to our system. You will need to open the document and save to a PDF format prior to sending through with your online referral.

Description

File Upload

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Referrer Details

At Each we ensure that we are delivering family centred practice and work together to achieve great outcomes. Please ensure that you have had a conversation with the family about this referral and gained the appropriate consent.

Are you an organisation?

YesNo

Please only fill out this section if the referrer is an organisation. If you are a parent, carer, guardian or child representative of the child, please go to Parent or Carer consent section on the next page.

Date

Organisation making referral

Contact Person

Phone Number

Email Address

Office Address

Street

Suburb

State

Postcode

The EC Partner may need to contact the professional listed above to better understand the child's circumstances and to ensure that the child is connected to the supports that best meet their needs.

Parent or Carer Consent

(This section must only be completed by a parent or legal guardian, the first 3 must be accepted to proceed))

I have read and understood the General Information and the Important Privacy Information provided with this information form. *

I understand how my child’s personal information and my own information will be collected, used and disclosed for the purposes of the NDIS, which is set out in the EACH Privacy Policy and Privacy / NDIS. *

I have carefully read all of the information provided in the referral form and confirm that it is accurate, complete and up to date. *

I consent to the EACH collecting, using and disclosing personal and sensitive information about my child in accordance with the General Information and Important Privacy Information sections in this document.

I understand that I may withdraw consent to receive support from an Early Childhood Partner at any time.

I give permission to contact the professional completing / assisting with this information form (if any)

I consent for my own and child details to be entered into the secure NDIS Pace business system.

I consent to the NDIS collecting your age and residence information from Centrelink using your Customer Reference Number (CRN)

Share information about you with identified third party organisations to help with developing and implementing your plan if an NDIS plan is an approved pathway.

I consent to the NDIA collecting, using and disclosing your personal and sensitive information for the above purposes including to verify your identity with the document issuer or official record holder via third party systems, and in accordance with our privacy policy.

Parent or Carer Details

(Please use names as per your legal identification documents, for example, your birth certificate)

First Name *

Middle Name

Surname *

Please select your relationship to the child

Date *

If so, please confirm that you have received verbal consent from the child’s parent, carer, guardian or child representative to make this referral *

If you would like to save and print a copy of your Referral Form before submitting please follow the steps below:

Select the 3-dot icon in your browser, top right corner and select print.
Printer, select Save as PDF
Pages, select All
Select Save and Print your referral

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