Children’s Health Queensland Hospital and Health Service Child Health Service Referral	(Affix patient identification label here)
Has this referral been discussed with the child’s Legal Guardian? Yes No CHILD DETAILS Family name: Given name: Date of birth: Gender: Preferred name: Address: Country of birth: Indigenous status: Aboriginal Torres Strait Islander Not stated/unknown Aboriginal AND Torres Strait Islander NOT Aboriginal or Torres Strait Islander Is the child of South Sea Islander descent? Yes No Alerts / allergies: PARENT, LEGAL GUARDIAN OR APPROVED FOSTER CARER DETAILS Legal Guardian: Parent/s Other: Parent / Guardian family name: Given name: Date of birth: Address (if different to child’s address): Suburb: Postcode: Home phone: Mobile: Interpreter required? Yes No Preferred language: REFERRAL INFORMATION Presenting concern and Parent or Legal Guardian’s goals: Relevant medical history: Relevant developmental history: Parent / carer / family psychosocial history: OTHER KEY CONTACTS Other agencies / therapy services involved: REFERRING AGENT DETAILS Name: Position: Organisation: Address: Phone: Email: Date: Click or tap to enter a date. External to Queensland Health please consider the Privacy Obligations for secure sending of Health Information. Please FAX your completed form to: 07 3139 6555 Queensland Health staff can submit a referral by: Saving form as a PDF Emailing the completed PDF to CHQ-CH-Referral@health.qld.gov.au Or printing and faxing to (07) 3068 3719

CHQ Referral enquiries – PH: 1300 245 126 More information: https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/child-health-service/