Referral

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).

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

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.

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 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;

• Information
• Referral to mainstream or community services;
• Short term early intervention supports; and
• Where required, assistance to access the NDIS.

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

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.

Custody / Court Orders

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.

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.

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.

Details of Developmental Delay

Previous Assessments / Additional Information

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 (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.

• 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.

• We keep your name and contact details on a client record.
• Other details such as plans, notes and other important information are also recorded.

• 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).