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Referral

Use this form to record information about a child aged 0 to 6 years with developmental concern/delay or disability who is seeking support through the NDIS.

Home › Early Years Services › Early Childhood Approach (NDIA) › Referral

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  • Parents and carers:

    After talking with your child's health or educational professional our early childhood partners can help you connect to the right supports. You do not need a referral or diagnosis from a medical professional to access support through our early childhood approach.

    If you require support to complete this referral you can contact us on 1300 012 293.

    Educators and professionals:

    When completing this form, we will ask you if families are informed and agree to this referral. This includes discussing the developmental information that you will provide to BCYF.

    Please note that if it is unclear whether a child meets the developmental criteria for access to the NDIS it is likely that a period of Early Supports will be offered prior to this step.

    Educators and professionals can arrange a secondary consultation and/or request a referral form by calling 1300 012 293.

    Eligibility – NDIS
  • Part 1 – General Information about ECEI

    Please use this form to record information about a child aged under seven years with developmental delay or disability who is seeking support through the National Disability Insurance Scheme (NDIS).

    What is ECEI?

    Early Childhood Early Intervention (ECEI) is funded by the NDIS. ECEI can offer a range of supports for eligible children under seven years.

    What is the aim of ECEI?

    The aim of ECEI is to provide parents and families with the knowledge, skills and support to optimise their child’s development and ability to participate in family, early childhood education and care settings, and in broader community life.

    Who can benefit from ECEI?

    A child aged under seven years who has either:

    • a developmental delay which is the result of an impairment and causes substantial functional limitations and who requires a coordinated, multidisciplinary service response; or
    • a disability; and
    • lives in the Barwon Region.
    The Early Childhood Partner’s role
    • The first contact point for families of children aged under seven years seeking support through the NDIS.
    • To determine with families/carers the most appropriate supports that would benefit and achieve outcomes for your child, tailored to their individual needs and circumstances;
    The types of supports provided by an Early Childhood Partner are:
    • Information
    • Referral to mainstream or community services;
    • Short term early intervention supports; and
    • Where required, assistance to access the NDIS.
    How to complete and submit this form

    This form may be completed by:

    • a family or carer, with the assistance of a professional
    • a professional working with the family/carer such as a GP, paediatrician
    Steps to complete and lodge this form:

    Complete the ECEI referral to Early Childhood Partner form and record parent/ carer/ guardian/ child representative consent.

    If consent is provided by the parent/ carer/ guardian/ child representative, please attach copies of any relevant assessments, reports or letters from health professionals that describe the child’s needs in support of this information form where appropriate.

    Further information regarding ECEI can be found at the following website: NDIS Website, ECEI Page or email ecei@bcyf.org.au or phone 1300 012 293.

  • Part 2 – ECEI Information Gathering

    This information assists the Early Childhood Partner to learn more about the child. Please provide information where appropriate and as agreed to by the child’s family, carer or guardian.

    Please read consent and privacy information on pages 8 through to 12 and seek signed consent where indicated.

  • Child Details

  • Please note this service is for children aged 0-7. If your child is 7 years or older, please contact the NDIS on 1800 800 110.
    DD slash MM slash YYYY
  • Parent / Carer Details

  • DD slash MM slash YYYY
  • (e.g. mother, father, grandparent)
  • (e.g. phone, letter, email)
  • DD slash MM slash YYYY
  • (e.g. mother, father, grandparent)
  • (e.g. phone, letter, email)
  • Custody / Court Orders

    The Early Childhood Partner needs to understand the environment that the child lives in and who best to contact about your child. This includes knowing about existing parenting, custody or guardianship arrangements.
  • Language / Interpreter

  • Child’s Disability and / or Developmental Delay

  • Please provide details of the professional who made the diagnosis or is undertaking the child’s assessment.

  • (i.e. recent hospitalisation, starting school soon etc.)
  • Details of Professional helping complete this form

    Details of the professional completing / assisting with this information form (if any).

    The Early Childhood Partner may need to contact the professional listed below to better understand your child’s circumstances and to ensure that your child is connected to the supports that best meet their needs.

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  • Additional Professionals / Services

    Please list the services and supports you are already using to help meet your child’s needs (e.g. GP, paediatrician, maternal & child health nurse, medical specialist, therapist etc.) and the services your child currently attends (e.g. childcare, kindergarten, occasional care etc.)

    The Early Childhood Partner may need to contact the people that you list to better understand your child’s circumstances and to ensure that your child is connected to the supports that best meet their needs.

  • Additional Professional/Service 1

  • Additional Professional/Service 2

  • Additional Professional/Service 3

  • Details of Developmental Delay

    Please ensure consent from family / carer / guardian prior to completing this section.
  • Self-Care (e.g. feeding / dressing / toileting etc. appropriate for age)
  • Describe the concerns regarding the child’s development

  • Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
  • Physical (e.g. gross and fine motor skills such as moving around / crawling / walking / sitting, rolling, using mobility aids etc.)
  • Describe the concerns regarding the child’s development

  • Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
  • Communication (Language and Speech) (e.g. understanding, talking and communicating needs with others appropriate for age, etc.)
  • Describe the concerns regarding the child’s development

  • Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
  • Relationships and Behaviour (e.g. social, skills, relating to others within the home or community environments etc.)
  • Describe the concerns regarding the child’s development

  • Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
  • Cognitive (Learning and Play) (e.g. learning, remembering and practicing new skills such as playing games, pretend play, etc.)
  • Describe the concerns regarding the child’s development

  • Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
  • Previous Assessments / Additional Information

    Please discuss with the family / carer / guardian the opportunity to attach copies of documents that describe the child’s needs that may support this information form. This is an option they may choose. The relevant documents may include medical assessment and reports, letters, screening assessments from health and/or educational professionals, court orders or other relevant parent/guardian/carer documents.
  • Please provide the detail of any assessments that the child has received (e.g. Hearing, Vision), or any additional information that may be relevant.
  • Drop files here or
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    • Part 3 – Important Privacy Information

      Please read this section carefully. If you have any questions, contact ECEI on ecei@bcyf.org.au

      Barwon Child, Youth & Family Privacy Policy
      • Barwon Child, Youth & Family (BCYF) is committed to ensuring the privacy and confidentiality of its clients.
      • We collect, manage and protect your personal information in line with privacy legislation and are guided by the Australian Privacy Principles, which regulate how we collect, use, hold and share your personal information.
      What is personal information?
      • Personal information is any information which identifies you. For example, your name, date-of-birth, nationality or heritage, home address and telephone number.
      • Personal information may also include information about your racial origin, religious beliefs, sexual preferences, criminal record and information about your health.
      What kinds of personal information do we collect and hold?
      • We keep your name and contact details on a client record.
      • Other details such as plans, notes and other important information are also recorded.
      Why do we collect and hold your information?
      • The information we collect helps us to keep up-to-date details about your needs, so we can provide you with the best possible service and support.
      • We only collect and record information that we need to support you.

      View full BCYF privacy policy

    • Parent / Carer Consent

      • I have read and understood the General Information (Part 1) and the Important Privacy Information (Part 3) provided with this information form.
      • I understand how my child’s personal information will be collected, used and disclosed for the purposes of the NDIS, which is set out in Part 3 of this information form.
      • I have carefully read all of the information provided in the information form and confirm that it is accurate, complete and up to date.
      • I consent to Barwon Child, Youth & Family 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 ECEI service provider at any time.
      • I give permission to contact the professional completing / assisting with this information form (if any).
    • Reset signature Signature locked. Reset to sign again
    • DD slash MM slash YYYY
    • DD slash MM slash YYYY
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      Max. file size: 10 MB, Max. files: 5.

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