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REFERRAL FORM Date Completed:
For this referral to be processed, please ensure all sections
are completed including: My Healthcare Rights, Privacy and
Consent.
The Queen Elizabeth Centre (QEC) is Victoria’s largest Early
Parenting Centre.
Our Vision is for children to get the best start in life.
We provide advice and a range of programs aimed at supporting
parents in their parenting journey.
Are you a parent/carer of a child less than 4 years of age?
Are you experiencing challenges in relation to your child’s
sleep and/or behaviour?
Are you seeking information and support in addressing these
concerns?
If so QEC may be able to help you.
To ensure that we can provide you with timely and appropriate
help could you please complete all sections of this referral form
and return to QEC.
This referral form can be completed by Parents/carers and/or
Health Professionals. We strongly recommend that the parent/carer
being referred to QEC is involved in the completion to this
form.
This form has been completed by: Self Health Professional
(please tick)
If Health Professional, please provide the following:
Name
Professional Role
Email
Phone Number
Please describe the main goal you would like QEC to help you
with:
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QEC is committed to protect your privacy. Information provided
in this form will be kept confidential and used only to support
your needs.
Details of family members:
ADMINISTRATION USE ONLY
UR No.:
Parent/Carer #1 Parent/Carer #2
Child/ren this referral relates to
Child 1 Child 2 (if applicable)
First Name
Surname
DOB
Medicare Details Number:
Ref no: _____
Expiry: ____ / ____
Number: (if different from Parent/Carer #1)
Ref no: _____
Expiry: ____ / ____
Number: (if different from Parent/Carer #1)
Ref no: _____
Expiry: ____ / ____
Number: (if different from Parent/Carer #1)
Ref no: _____
Expiry: ____ / ____
Do you have a Healthcare Card?
Yes No Yes No
Address
Contact Number N/A N/A
Contact Email
Gender M F Other M F Other M F Other M F Other
Marital Status Single Married
Defacto Separated
Single Married
Defacto Separated
N/A N/A
Country of Birth
Year of arrival (if not born in Australia)
What ethnicity do you identify with? Language spoken at
home?
Do you need an Interpreter? Yes No
If Yes, please specify what language:
Aboriginal Yes No Yes No Yes No Yes No
Torres Strait Islander
Yes No Yes No Yes No Yes No
Education Level Year 9-10 VCE or equivalent Diploma
DegreeMasters Little or no schooling Other
Year 9-10 VCE or equivalent Diploma DegreeMasters Little or no
schooling Other
N/A N/A
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Family Income Jobsearch Employed Family Assistance Single Parent
Support Disability Support Young Homeless
Allowance Other
Employment type:
______________________
______________________ (Family income details not required for
Parent/Carer #2)
N/A N/A
Learning Style Do you learn best by (choose all that apply):
Reading Seeing pictures and
diagrams Being shown how to do
something Doing it yourself
Do you learn best by (choose all that apply): Reading Seeing
pictures and
diagrams Being shown how to do
something Doing it yourself
N/A N/A
Please select all the options that you can use for Telehealth
purposes: Phone calls SMS Whatsapp video calls Facetime Zoom video
call app Other – please name:
________________________________________________________________________
Please provide details of any of the following services you are
engaged with:
Service Name Phone No. Address
GP
Maternal & Child Health
Other (e.g. paediatrician, psychologist, psychiatrist)
Other
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Private & Confidential ADMINISTRATION USE ONLY
HISTORY: Please complete the following:
Parent/Carer #1 Parent/Carer #2 Child/ren this referral relates
to Child 1 Child 2 (if applicable)
Allergies Yes No Yes No Yes No Yes NoDetails If yes: If yes: If
yes: If yes:
Special dietary requirements?
Yes No Yes No Yes No Yes NoDetails: Details: Details:
Details:
Anxiety Yes No Yes No Yes No Yes NoAttachment/bonding concerns
Yes No Yes No Yes No Yes No
Behavioural concerns Yes No Yes No Yes No Yes No
Intellectual disability Yes No Yes No Yes No Yes No
Learning difficulty Yes No Yes No Yes No Yes No
Physical disability Yes No Yes No Yes No Yes No
Post-natal depression Yes No Yes No N/A N/APsychiatric illness
Yes No Yes No Yes No Yes NoSleep issues Yes No Yes No Yes No Yes
No
Any other medical condition Details:
Yes No Yes No Yes No Yes NoIf Yes: If Yes: If Yes: If Yes:
Child details
Gestational age at birth (number of weeks)
Baby weight at birth in grams
Child’s current weight in grams
Your child’s development for his/her age is Good Average
Poor
Additional Child (if applicable)
Gestational age at birth (number of weeks)
Baby weight at birth in grams
Child’s current weight in grams
Your child’s development for his/her age is Good Average
Poor
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Private & Confidential
Parent/Primary Carer
Your general health Good Average Poor
Are you taking any medication? Yes NoIf yes, please list
here:
Is the Child on any medication? Yes NoIf yes, please list
here:
How often do you have an alcoholic drink of any kind? Every day
5-6 days/week 3-4 days/week 1-2 days/week 2-3 times/month about 1
day/month less often Never
Are you a smoker? Yes No
How would you describe the current level of support you receive
from your partner?
High Average Low
How would you describe the current level of support you receive
from family and/or friends?
High Average Low
How happy are you about the job you are doing as a parent?
Very Happy Happy Mixed Unhappy Very Unhappy
How happy are you with the way you get on with your
children?
Very Happy Happy Mixed Unhappy Very Unhappy
How happy are you with the way your children behave? Very Happy
Happy Mixed Unhappy Very Unhappy
Have you experienced family violence? Yes No
Are you in anyway worried about the safety of yourself or your
children? Yes No
Please provide any other relevant information:
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Private & Confidential
Your Rights, Privacy and Consent
Please Note: For this Referral to be processed the following
sections will need to be completed.
My Healthcare Rights
Please refer to Appendix 1 - My Healthcare Rights. Please ensure
you have read and understood your rights.
In summary, you have the right to:
1. Access services that meet your needs2. Safety3. Respect –
being treated as an individual with dignity and having your
culture, identity, beliefs and choices
recognised and respected4. Partnership – to ask questions, be
involved in open and honest community, make decisions and include
other
people in decision making5. Information – clear information so
that you can understand the care being given.6. Privacy7. Give
feedback. You can provide feedback or make a complaint in three
ways: firstly can provide feedback
directly to each worker that contacts you, secondly via the
feedback section of our website and thirdly via anexit survey link
that we will send out at the end of the program.
Have you read ‘My Healthcare Rights’ and understand your rights?
� Yes � No
Privacy
Please refer to Appendix 2 – Your Privacy. The privacy flyer
explains how we use information that we collect about you.
Have you read ‘Your Privacy’ flyer and understand how we use
your health information? � Yes � No
Consent
It is important to us that we have your consent in a few
important areas.
1. Do you consent to participate in a QEC Program? � Yes �
No
2. Do you consent to us sharing information that we collect with
the following services?
� Your family’s Maternal and Child Health Nurse. If yes, write
name: _______________________________
� Your doctor. If yes, write name:
___________________________________________________________
� Your child’s doctor. If yes, write name:
_____________________________________________________
� Your child’s Paediatrician. If yes, write name:
________________________________________________
� Any other agencies or health professionals. If yes, write
name: __________________________________
3. At times, your information may be used to improve our
service. External auditors or researchers may be engaged toreview
health records and develop reports. This information will always be
de-identified and kept confidential.Do you agree to be a part of
this research? � Yes � No
Thank you for completing this referral. Please return your
referral via email, fax or post:
Email to: [email protected] with 'New Referral' in email subject
line Fax: 03 9549 2779 Mail: 53 Thomas St, Noble Park, VIC 3174
mailto:[email protected]
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My healthcare rightsThis is the second edition of the Australian
Charter of Healthcare Rights.
These rights apply to all people in all places where health care
is provided in Australia.
The Charter describes what you, or someone you care for, can
expect when receiving health care.
I have a right to:
Access ��Healthcare�services�and�treatment�that�meets�my�needs
Safety ��Receive�safe�and�high�quality�health�care�that�meets�national�standards ��Be�cared�for�in�an�environment�that�is�safe�and�makes�me�feel�safe
Respect ��Be�treated�as�an�individual,�and�with�dignity�and�respect �����Have�my�culture,�identity,�beliefs�and�choices�recognised�and�respected
Partnership ����Ask�questions�and�be�involved�in�open�and�honest�communication ����Make�decisions�with�my�healthcare�provider,�to�the�extent�that�I��choose�and�am�able�to ��Include�the�people�that�I�want�in�planning�and�decision-making
Information ���Clear�information�about�my�condition,�the�possible�benefits�and�risks��of�different�tests�and�treatments,�so�I�can�give�my�informed�consent ���Receive�information�about�services,�waiting�times�and�costs ��Be�given�assistance,�when�I�need�it,�to�help�me�to�understand�and��use�health�information� ���Access�my�health�information ��Be�told�if�something�has�gone�wrong�during�my�health�care,�how�it��happened,�how�it�may�affect�me�and�what�is�being�done�to�make��care�safe
Privacy ��Have�my�personal�privacy�respected� ��Have�information�about�me�and�my�health�kept�secure�and�confidential�
Give
feedback ��Provide�feedback�or�make�a�complaint�without�it�affecting�the�way��that�I�am�treated ������Have�my�concerns�addressed�in�a�transparent�and�timely�way ��Share�my�experience�and�participate�to�improve�the�quality�of�care��and�health�services�
PUBL
ISH
ED JU
LY 2
019
For more information ask a member of staff or
visitsafetyandquality.gov.au/your-rights
https://www.safetyandquality.gov.au/national-priorities/charter-of-healthcare-rights/emihatTypewritten
TextAppendix 1
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© QEC 2020 It is illegal to photocopy or reproduce this document
without written permission Uncontrolled if downloaded
QEC recognises every person’s right to privacy. We want families
to know how we use health information.
What happens to your information? We keep a health record for
all families accessing our services. The record contains contact
details and information about the care given to families. This
record is kept up-to-date and held securely. We keep records for a
specific number of years and then the record is securely destroyed.
QEC maintains strict procedures about the use of health
information. In additional, all employees are bound by a strict
code of conduct which includes confidentiality. We collect
information in order to provide the best possible care for your
family. If you choose not to tell us important information, it may
affect the quality of the care that we can provide. We ask that you
provide accurate and complete information for the safety of you and
your family.
Who has access to your information? All employees providing your
care have access to your health records. We will only provide
information to other services with your consent or if required by
law. These other services may include:
• Your General Practitioner (GP) • Your Maternal and Child
Health Nurse • Specialist medical practitioners • Department of
Health and Human Services.
In some circumstances QEC is obliged by law to release
information from your health record, for example: • Presentation of
your record as evidence in court when subpoenaed (e.g. in case of
legal action) • Reporting of basic information about you to the
Department of Health and Human Services, such as
age, gender and the suburb in which you live, but not your name
• Reporting notifiable circumstances or diseases (e.g. some
infectious diseases) to the Victorian
Department of Health and Human Services • Notification to our
third party indemnity insurers in circumstances which may give rise
to a claim.
Quality Improvement and Research At times files will be audited
or checked to ensure that the information is accurate and complete.
Your personal information is not collected or recorded during
audits. The audits are conducted by employees or by an
accreditation service, as required by our funding body. As
necessary, de-identified information from health records may also
be used for staff development, program reviews, future planning and
evaluation. Information from your health record will only be used
for research purposes with your consent and if the project has been
approved by an ethics and research committee.
How can you gain access to information about you? In accordance
with the Health Records Act 2001 (VIC) you have the right to
request access to your health record. A fee may be charged for this
service. If there is information in the record which is incorrect
or with which you do not agree, you have the right to request that
it be amended. Requests for access to your health record can be
made in writing to: The QEC Privacy Officer - 53 Thomas Street
Noble Park 3174.
Your Privacy
emihatTypewritten TextAppendix 2
emihatTypewritten Text
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Updated December 2020. © QEC 2020 IT IS ILLEGAL TO REPRODUCE OR
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Private & Confidential
ADMINISTRATION USE ONLY Date Received UR No.
Phone Call: Completed
Date:
Attempted –Unsuccessful
Date:
Date:
Date:
Date:
Date:
Scheduled for later:
Day:
AM/PM:
Programs referred to: Residential Daystay Parenting Plus
Playsteps – Noble Park Gippsland S & S Advice
Telehealth Other (please specify):
NOTES:
Date Completed: Are you a parentcarer of a child less than 4
years of age: OffAre you experiencing challenges in relation to
your childs sleep andor behaviour: OffAre you seeking information
and support in addressing these concerns: OffSelf: OffHealth
Professional please tick: OffName: Professional Role: Email: Phone
Number: Please describe the main goal you would like QEC to help
you with: ParentCarer 1First Name: ParentCarer 2First Name: Child
1First Name: Child 2 if applicableFirst Name: ParentCarer 1Surname:
ParentCarer 2Surname: Child 1Surname: Child 2 if applicableSurname:
ParentCarer 2DOB: Child 1DOB: Child 2 if applicableDOB: Ref no: Ref
no_2: Ref no_3: Ref no_4: Expiry: undefined: Expiry_2: undefined_2:
Expiry_3: undefined_3: Expiry_4: undefined_4: undefined_5:
Offundefined_6: OffYes NoAddress: Yes NoAddress_2: Number if
different from ParentCarer 1 Ref no Expiry Address: Number if
different from ParentCarer 1 Ref no Expiry Address_2: Yes NoContact
Number: Yes NoContact Number_2: Contact Email: undefined_7:
Offundefined_8: Offundefined_9: Offundefined_10: OffSingle:
OffDefacto: OffMarried: OffSeparated: OffSingle_2: OffDefacto_2:
OffMarried_2: OffSeparated_2: OffSingle Married Defacto
SeparatedCountry of Birth: Single Married Defacto SeparatedCountry
of Birth_2: NACountry of Birth: NACountry of Birth_2: Single
Married Defacto SeparatedYear of arrival if not born in Australia:
Single Married Defacto SeparatedYear of arrival if not born in
Australia_2: NAYear of arrival if not born in Australia: NAYear of
arrival if not born in Australia_2: Single Married Defacto
SeparatedWhat ethnicity do you identify with: Single Married
Defacto SeparatedWhat ethnicity do you identify with_2: NAWhat
ethnicity do you identify with: NAWhat ethnicity do you identify
with_2: Single Married Defacto SeparatedLanguage spoken at home:
Interpreter: OffIf Yes please specify what language: undefined_11:
Offundefined_12: Offundefined_13: Offundefined_14: Offundefined_15:
Offundefined_16: Offundefined_17: Offundefined_18: Offundefined_19:
Offundefined_20: Offundefined_21: Offundefined_22: Offundefined_23:
Offundefined_24: Offundefined_25: Offundefined_26: OffYear 910:
OffVCE or equivalent: OffDiploma: OffDegree: OffMasters: OffLittle
or no schooling: OffOther_5: OffYear 910_2: OffVCE or equivalent_2:
OffDiploma_2: OffDegree_2: OffMasters_2: OffLittle or no
schooling_2: OffOther_6: OffJobsearch: OffEmployed: OffFamily
Assistance: OffSingle Parent Support: OffDisability Support:
OffYoung Homeless: OffOther_7: OffJobsearch Employed Family
Assistance Single Parent Support Disability Support Young Homeless
Allowance Other: Reading: OffSeeing pictures and: OffBeing shown
how to do: OffDoing it yourself: OffReading_2: OffSeeing pictures
and_2: OffBeing shown how to do_2: OffDoing it yourself_2: OffPhone
calls: OffSMS: OffWhatsapp video calls: OffFacetime: OffZoom video
call app: Offundefined_27: OffOther please name: NameGP:
NameMaternal Child Health: Phone NoMaternal Child Health: NameOther
eg paediatrician psychologist psychiatrist: Phone NoOther eg
paediatrician psychologist psychiatrist: NameOther: Phone NoOther:
Yes No If yes: If yes: OffYes No If yes_2: If yes_2: OffYes No If
yes_3: If yes_3: OffYes No If yes_4: If yes_4: OffYes No Details:
Details: OffYes No Details_2: Details_2: OffYes No Details_3:
Details_3: OffYes No Details_4: Details_4: Offundefined_28:
Offundefined_29: Offundefined_30: Offundefined_31: Offundefined_32:
Offundefined_33: Offundefined_34: Offundefined_35: Offundefined_36:
Offundefined_37: Offundefined_38: Offundefined_39: Offundefined_40:
Offundefined_41: Offundefined_42: Offundefined_43: Offundefined_44:
Offundefined_45: Offundefined_46: Offundefined_47: Offundefined_48:
Offundefined_49: Offundefined_50: Offundefined_51: Offundefined_52:
Offundefined_53: Offundefined_54: Offundefined_55: Offundefined_56:
Offundefined_57: Offundefined_58: Offundefined_59: Offundefined_60:
Offundefined_61: Offundefined_62: Offundefined_63: Offundefined_64:
Offundefined_65: Offundefined_66: Offundefined_67: Offundefined_68:
Offundefined_69: Offundefined_70: Offundefined_71: Offundefined_72:
Offundefined_73: Offundefined_74: Offundefined_75: OffYes No If
Yes: If Yes: OffYes No If Yes_2: If Yes_2: OffYes No If Yes_3: If
Yes_3: OffYes No If Yes_4: If Yes_4: OffGestational age at birth
number of weeks: Baby weight at birth in grams: Childs current
weight in grams: Good: OffAverage: OffPoor: OffGestational age at
birth number of weeks_2: Baby weight at birth in grams_2: Childs
current weight in grams_2: undefined_76: Offundefined_77:
Offundefined_78: Offundefined_79: Offundefined_80: Offundefined_81:
OffIf yes please list here: undefined_82: OffIf yes please list
here_2: undefined_83: OffEvery day: Off34 daysweek: Off23
timesmonth: Offless often: Off56 daysweek: Off12 daysweek: Offabout
1 daymonth: OffNever: Offundefined_84: Offundefined_85:
Offundefined_86: Offundefined_87: Offundefined_88: Offundefined_89:
Offundefined_90: Offundefined_91: Offundefined_92: Offundefined_93:
Offundefined_94: Offundefined_95: Offundefined_96: Offundefined_97:
Offundefined_98: Offundefined_99: Offundefined_100:
Offundefined_101: Offundefined_102: Offundefined_103:
Offundefined_104: Offundefined_105: Offundefined_106:
Offundefined_108: Offundefined_109: Offundefined_110: OffPlease
provide any other relevant information: Your familys Maternal and
Child Health Nurse If yes write name: Your doctor If yes write
name: Your childs doctor If yes write name: Your childs
Paediatrician If yes write name: Any other agencies or health
professionals If yes write name: Check Box1: OffCheck Box2:
OffCheck Box8: OffCheck Box9: Offundefined_107: OffCheck Box6:
OffCheck Box7: OffCheck Box5: OffCheck Box3: OffPhone NoGP: Address
1: Address 2: Address 3: Address 4: Medicare 1: ParentCarer 1DOB:
Medicare 2: Medicare 3: Medicare 4: