Telehealth Child referral form

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Unit 3, 56 Hudson St, Hamilton NSW 2303

(02) 4969 8060

Educational Case
Management

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BROCHURE

Telehealth

Child Referral Form

I confirm that I would like to receive Telehealth therapy from ECM

Which state or territory do you reside in?

Child First Name

Child Last Name

Gender

Male

Female

Birthday

Address

School

Year at School

School Phone

Teacher's name

Siblings Name/s and age/s

Medical Information

Family Doctor

Doctor Phone

Medical Condition/Previous Diagnosis - if applicable

Medication(s)

Referrer's name and agency - if not the family Doctor

Medicare Number

Number on card

NDIS number

Date commenced

Do you have a Mental Health Care plan?

Yes

No

Do you have an Enhanced Care Plan?

Yes

No

Mother's details

Mother's Full Name

Mother's Phone

Mother's Address

Mother's Occupation

Mother's Email

Mother's Family History - Mental Health

Yes

No

Mother's Family History - Learning Problems

Yes

No

Mother's main concern

Father's Details

Father's Full Name

Father's Phone

Father's Address

Father's Occupation

Father's Email

Father's Family History - Mental Health

Yes

No

Father's Family History - Learning Problems

Yes

No

Father's main concern

Living Arrangements

Primary Carer(s)

Current Custody Arrangements (if applicable)

Languages Spoken at Home

Case Manager

Organisation

Case Manager Email Address

Contact us

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Educational Case Management Pty Ltd ABN: 43609946698

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