Referrals

Details of child

First Name *

Surname *

Address

Suburb

State

Postcode

Date of birth (dd/mm/yyyy) *

Gender *

Australian Residency Status *

Permanent

Temporary

OtherOther

Current school or child care

Child's Centrelink Number (CRN)

Details of parents(s) / guardian(s)

First Name *

Surname *

Relationship to child

Is this person the child's legal guardian?

Yes

No

Parent/guardian 1 address *

Same as child's

Different address

Address

Suburb

State

Postcode

Country

First Name

Surname

Relationship to child

Is this person the child's legal guardian?

Yes

No

Parent/guardian 2 address

Same as child's

Different address

Address

Suburb

State

Postcode

Primary phone number *

Alternate phone number

Email address *

Details of referral: explain what goals you are wanting to achieve.

*

Please attach copies of diagnostic reports (if available)

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 required *

I’m not sure what support I need

Dog-Assisted Therapy

Dietetics

Exercise Physiology

Occupational Therapy

Physiotherapy / Hydrotherapy

Psychology

Social Work

Speech Pathology

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

Preferred times for services

Before school

Schooltime

After school

Available funding *

Please upload your child's NDIS plan.

Maximum file size: 5MB

Please upload your child's GP Care Plan. You will only be eligible for Medicare rebates with a Care Plan. If your child does not have a current Care Plan, you will need to make an appointment with your GP or select another funding option to continue.

Maximum file size: 5MB

How did you find out about Kites Children’s Therapy? How did you find out about Kites Children’s Therapy?

Contact details for referee

Complete this section only if the referee 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.

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Physiotherapy for Kids - immediate availability!

Details of child

Details of parents(s) / guardian(s)

Details of referral: explain what goals you are wanting to achieve.

Swallowing/Choking (Dysphagia)

Positive Behaviour Support

Contact details for referee