Refer A Child - Paediatric Collective

About the Child

Child’s first name

Child’s last name

Child’s age

Date of Birth

Suburb / Town

Postcode

About you

Name

First

Last

Your relationship to the child

Phone

Email

What type of support are you looking for?

Birth you yes,

Is there a particular practitioner you would like to see?

No preference
Yes

If yes, please enter the practitioner’s name

Funding

How will you be funding your appointments? (Please select all that apply)

Others

Funding options, fees and eligibility vary between independent practitioners and will be discussed directly with you by the practitioner.

Where did you hear about us?

Privacy and referral consent

Paediatric Collective operates a referral pathway connecting families and referrers with independent practitioners. Information submitted through this form will be used to receive, manage and progress your referral and may be provided to an appropriate independent practitioner within the Paediatric Collective network for this purpose. Please do not include medical records, diagnoses, clinical histories or other sensitive health information in this form. If clinical or health information is required, the practitioner will collect this directly from you. Once an independent practitioner accepts your referral, they are responsible for the information they collect in providing their services, in accordance with their own privacy and professional obligations. Please read our Privacy Policy for information about how Paediatric Collective handles personal information.

Please confirm your consent by ticking the checkbox below.

I confirm that I am authorised to provide the information contained in this referral and agree to Paediatric Collective using and disclosing this information for the purpose of progressing the referral and connecting the child with an appropriate independent practitioner.