Parent Self-Referral Form

We know these are challenging and unchartered times and the COVID-19 situation is changing rapidly.  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 contact you to organise the right support for you. As of March 30th all services will be provided using Telehealth (video/phone calls). 

This is a new process, parents please fill out as much of the form as you can.
You will need to enter your email address in the referring agent email, this is mandatory. 

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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