Karitane Referral Form

Referral to Karitane services including residential, day stay and outreach is to be made by a health professional only (Child and Family Health Nurse, doctor or social worker – not related to the family). Families cannot self-refer.

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Download the GP Letter this is to be completed by client’s GP (child and adult if using either prescribed or over the counter medications. Please also download and print the Consumer Facts for Medication and give to the parent. Karitane is striving to “Promote the best possible medication history” for all of our clients.

Download your guide to making a referral

If you experience difficulty submitting the online form you, it is also available in PDF format to download and complete.

To discuss a referral, please contact Karitane on (02) 9794 2300 or email karitane.referrals@sswahs.nsw.gov.au.

Fields marked with '*' are mandatory.

Family Details - Parent or Carer
First Name(s)*
Last Name*
Date of Birth (dd/mm/yyyy)*
Contact Number (mobile preferred)*
Email
Address*
Town/Suburb*
State*
Postcode*
Marital Status*
Relationship to Presenting Child/ren*
Country of Birth of Mother*
Aboriginal or Torres Strait Island Status*
If an interpreter is required, what language?
Presenting Child/ren Details
Number of children for admission*
Any existing care orders in place for the child/ren*
First nameLast nameDate of birth (dd/mm/yyyy)Sex of the Child
Child 1*
Child 2
Child 3
Reasons for Referral
Primary reason for referral*
Secondary reason for referral
Has a physical check been performed?
Note: Doctors may wish to use the Karitane Referral/Physical Health Check form.
Is your client currently in the care of a
EDS Score (if known)
EDS Date (dd/mm/yyyy)
Q10 score
Note: Referrers may wish to access the Edinburgh Depression Scale form.
Any intervention previously undertakenBy whomDate (dd/mm/yyyy)
Referring Agent Details
Referral Date29/04/17
Provider Number
First Name(s)*
Last Name*
Profession*
Contact number*
Address*
Email*
Postcode*
Best time to contact you
Further comments
The primary carer has consented to this referral*
 
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