Referral —

Camp Kiah Play Therapy Referral

Young Person Name *

First Name

Last Name

Date Of Birth

Address *

School/ Kinder *

Name and year level

Referrer details: *

Name, organisation and best contact

Carer details: *

Name, relationship and best contact

Legal guardian

in the event different to carer

Events leading to referral

Reasons for referral

Brief family history

May contain which family members live with young person and those who don't

Current presenting concerns

Sleeping

Eating

Toileting

Self harm

Sexualised behaviours

Social/ peer relationships

Other

Diagnosis

ASD

ADHD

Anxiety

Environmental Trauma

Intellectual Disability

FASD

Learning difficulty

Other

Funding source

Person financially responsible for sessions

Thank you for your referral!

Our allocation meetings occur on Tuesdays. It is hopeful that someone will be in touch following our next meeting to update you on the waitlist/ progress of your referral.

Please email us if you haveany pessig concerns.

Melbourne , Australia0407091436laura.childrenatplay@gmail.com