Referral Form

We know these are challenging and unchartered times and the COVID-19 situation is constantly changing.  We also know that now more than ever parents need support which is why parents can now self-refer by completing the form below (Health Professionals can still use the below form). Once we process your referral our Intake team will make contact to organise the right support for you. Due to increasing demand we are unable to take new referrals to the Toddler Clinic (including I-PCIT), Karitane Kids Behaviour Clinic and Jade House. We are working very hard to be able to re-open our books for these three services and we appreciate your patience as we work through our current waitlist. If you have a parenting question please call our Careline 1300 227 464.

Parents if you are self-referring please add your details below. Please then select ‘self-referral’ from the profession drop down list.

This application is to be completed by health professionals only. Families cannot self-refer. Once your referral has been processed your client will receive a text from our team to contact Intake and action their referral. 

Family Details

Parent or Carer (That will attend Karitane)

Alternative Parent or Carer Details

Presenting Child/ren Details



Reasons for Referral

Other Specialists

EDS Form

Referring Agent


Required fields are marked with a *

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