Private & Confidential REFERRAL FORM Referral...7. Give feedback. You can provide feedback or make a...

Private & Confidential

Updated December 2020. © QEC 2020 IT IS ILLEGAL TO REPRODUCE OR PHOTOCOPY THIS DOCUMENT WITHOUT WRITTEN PERMISSION Page 1 of 6

REFERRAL FORM Date Completed:

For this referral to be processed, please ensure all sections are completed including: My Healthcare Rights, Privacy and Consent.

The Queen Elizabeth Centre (QEC) is Victoria’s largest Early Parenting Centre.

Our Vision is for children to get the best start in life.

We provide advice and a range of programs aimed at supporting parents in their parenting journey.

Are you a parent/carer of a child less than 4 years of age?

Are you experiencing challenges in relation to your child’s sleep and/or behaviour?

Are you seeking information and support in addressing these concerns?

If so QEC may be able to help you.

To ensure that we can provide you with timely and appropriate help could you please complete all sections of this referral form and return to QEC.

This referral form can be completed by Parents/carers and/or Health Professionals. We strongly recommend that the parent/carer being referred to QEC is involved in the completion to this form.

This form has been completed by: Self Health Professional (please tick)

If Health Professional, please provide the following:

Name

Professional Role

Email

Phone Number

Please describe the main goal you would like QEC to help you with:



QEC is committed to protect your privacy. Information provided in this form will be kept confidential and used only to support your needs.

Details of family members:

ADMINISTRATION USE ONLY

UR No.:

Parent/Carer #1 Parent/Carer #2

Child/ren this referral relates to

Child 1 Child 2 (if applicable)

First Name

Surname

DOB

Medicare Details Number:

Ref no: _____

Expiry: ____ / ____

Number: (if different from Parent/Carer #1)

Ref no: _____

Expiry: ____ / ____


Ref no: _____

Expiry: ____ / ____


Ref no: _____

Expiry: ____ / ____

Do you have a Healthcare Card?

Yes No Yes No

Address

Contact Number N/A N/A

Contact Email

Gender M F Other M F Other M F Other M F Other

Marital Status Single Married

Defacto Separated

Single Married

Defacto Separated

N/A N/A

Country of Birth

Year of arrival (if not born in Australia)

What ethnicity do you identify with? Language spoken at home?

Do you need an Interpreter? Yes No

If Yes, please specify what language:

Aboriginal Yes No Yes No Yes No Yes No

Torres Strait Islander

Yes No Yes No Yes No Yes No

Education Level Year 9-10 VCE or equivalent Diploma DegreeMasters Little or no schooling Other

Year 9-10 VCE or equivalent Diploma DegreeMasters Little or no schooling Other

N/A N/A



Family Income Jobsearch Employed Family Assistance Single Parent Support Disability Support Young Homeless

Allowance Other

Employment type:

______________________

______________________ (Family income details not required for Parent/Carer #2)

N/A N/A

Learning Style Do you learn best by (choose all that apply): Reading Seeing pictures and

diagrams Being shown how to do

something Doing it yourself

Do you learn best by (choose all that apply): Reading Seeing pictures and

diagrams Being shown how to do

something Doing it yourself

N/A N/A

Please select all the options that you can use for Telehealth purposes: Phone calls SMS Whatsapp video calls Facetime Zoom video call app Other – please name: ________________________________________________________________________

Please provide details of any of the following services you are engaged with:

Service Name Phone No. Address

GP

Maternal & Child Health

Other (e.g. paediatrician, psychologist, psychiatrist)

Other


Private & Confidential ADMINISTRATION USE ONLY

HISTORY: Please complete the following:

Parent/Carer #1 Parent/Carer #2 Child/ren this referral relates to Child 1 Child 2 (if applicable)

Allergies Yes No Yes No Yes No Yes NoDetails If yes: If yes: If yes: If yes:

Special dietary requirements?

Yes No Yes No Yes No Yes NoDetails: Details: Details: Details:

Anxiety Yes No Yes No Yes No Yes NoAttachment/bonding concerns Yes No Yes No Yes No Yes No

Behavioural concerns Yes No Yes No Yes No Yes No

Intellectual disability Yes No Yes No Yes No Yes No

Learning difficulty Yes No Yes No Yes No Yes No

Physical disability Yes No Yes No Yes No Yes No

Post-natal depression Yes No Yes No N/A N/APsychiatric illness Yes No Yes No Yes No Yes NoSleep issues Yes No Yes No Yes No Yes No

Any other medical condition Details:

Yes No Yes No Yes No Yes NoIf Yes: If Yes: If Yes: If Yes:

Child details

Gestational age at birth (number of weeks)

Baby weight at birth in grams

Child’s current weight in grams

Your child’s development for his/her age is Good Average Poor

Additional Child (if applicable)

Gestational age at birth (number of weeks)

Baby weight at birth in grams

Child’s current weight in grams

Your child’s development for his/her age is Good Average Poor



Parent/Primary Carer

Your general health Good Average Poor

Are you taking any medication? Yes NoIf yes, please list here:

Is the Child on any medication? Yes NoIf yes, please list here:

How often do you have an alcoholic drink of any kind? Every day 5-6 days/week 3-4 days/week 1-2 days/week 2-3 times/month about 1 day/month less often Never

Are you a smoker? Yes No

How would you describe the current level of support you receive from your partner?

High Average Low

How would you describe the current level of support you receive from family and/or friends?

High Average Low

How happy are you about the job you are doing as a parent?

Very Happy Happy Mixed Unhappy Very Unhappy

How happy are you with the way you get on with your children?

Very Happy Happy Mixed Unhappy Very Unhappy

How happy are you with the way your children behave? Very Happy Happy Mixed Unhappy Very Unhappy

Have you experienced family violence? Yes No

Are you in anyway worried about the safety of yourself or your children? Yes No

Please provide any other relevant information:



Your Rights, Privacy and Consent

Please Note: For this Referral to be processed the following sections will need to be completed.

My Healthcare Rights

Please refer to Appendix 1 - My Healthcare Rights. Please ensure you have read and understood your rights.

In summary, you have the right to:

1. Access services that meet your needs2. Safety3. Respect – being treated as an individual with dignity and having your culture, identity, beliefs and choices

recognised and respected4. Partnership – to ask questions, be involved in open and honest community, make decisions and include other

people in decision making5. Information – clear information so that you can understand the care being given.6. Privacy7. Give feedback. You can provide feedback or make a complaint in three ways: firstly can provide feedback

directly to each worker that contacts you, secondly via the feedback section of our website and thirdly via anexit survey link that we will send out at the end of the program.

Have you read ‘My Healthcare Rights’ and understand your rights? � Yes � No

Privacy

Please refer to Appendix 2 – Your Privacy. The privacy flyer explains how we use information that we collect about you.

Have you read ‘Your Privacy’ flyer and understand how we use your health information? � Yes � No

Consent

It is important to us that we have your consent in a few important areas.

1. Do you consent to participate in a QEC Program? � Yes � No

2. Do you consent to us sharing information that we collect with the following services?

� Your family’s Maternal and Child Health Nurse. If yes, write name: _______________________________

� Your doctor. If yes, write name: ___________________________________________________________

� Your child’s doctor. If yes, write name: _____________________________________________________

� Your child’s Paediatrician. If yes, write name: ________________________________________________

� Any other agencies or health professionals. If yes, write name: __________________________________

3. At times, your information may be used to improve our service. External auditors or researchers may be engaged toreview health records and develop reports. This information will always be de-identified and kept confidential.Do you agree to be a part of this research? � Yes � No

Thank you for completing this referral. Please return your referral via email, fax or post:

Email to: [email protected] with 'New Referral' in email subject line Fax: 03 9549 2779 Mail: 53 Thomas St, Noble Park, VIC 3174

mailto:[email protected]

My healthcare rightsThis is the second edition of the Australian Charter of Healthcare Rights.

These rights apply to all people in all places where health care is provided in Australia.

The Charter describes what you, or someone you care for, can expect when receiving health care.

I have a right to: Access ��Healthcare�services�and�treatment�that�meets�my�needs

Safety ��Receive�safe�and�high�quality�health�care�that�meets�national�standards ��Be�cared�for�in�an�environment�that�is�safe�and�makes�me�feel�safe

Respect ��Be�treated�as�an�individual,�and�with�dignity�and�respect ��Have�my�culture,�identity,�beliefs�and�choices�recognised�and�respected

Partnership ��Ask�questions�and�be�involved�in�open�and�honest�communication ��Make�decisions�with�my�healthcare�provider,�to�the�extent�that�I��choose�and�am�able�to ��Include�the�people�that�I�want�in�planning�and�decision-making

Information ��Clear�information�about�my�condition,�the�possible�benefits�and�risks��of�different�tests�and�treatments,�so�I�can�give�my�informed�consent ��Receive�information�about�services,�waiting�times�and�costs ��Be�given�assistance,�when�I�need�it,�to�help�me�to�understand�and��use�health�information� ��Access�my�health�information ��Be�told�if�something�has�gone�wrong�during�my�health�care,�how�it��happened,�how�it�may�affect�me�and�what�is�being�done�to�make��care�safe

Privacy ��Have�my�personal�privacy�respected� ��Have�information�about�me�and�my�health�kept�secure�and�confidential�

Give feedback ��Provide�feedback�or�make�a�complaint�without�it�affecting�the�way��that�I�am�treated ��Have�my�concerns�addressed�in�a�transparent�and�timely�way ��Share�my�experience�and�participate�to�improve�the�quality�of�care��and�health�services�

PUBL

ISH

ED JU

LY 2

019

For more information ask a member of staff or visitsafetyandquality.gov.au/your-rights

https://www.safetyandquality.gov.au/national-priorities/charter-of-healthcare-rights/emihatTypewritten TextAppendix 1

© QEC 2020 It is illegal to photocopy or reproduce this document without written permission Uncontrolled if downloaded

QEC recognises every person’s right to privacy. We want families to know how we use health information.

What happens to your information? We keep a health record for all families accessing our services. The record contains contact details and information about the care given to families. This record is kept up-to-date and held securely. We keep records for a specific number of years and then the record is securely destroyed. QEC maintains strict procedures about the use of health information. In additional, all employees are bound by a strict code of conduct which includes confidentiality. We collect information in order to provide the best possible care for your family. If you choose not to tell us important information, it may affect the quality of the care that we can provide. We ask that you provide accurate and complete information for the safety of you and your family.

Who has access to your information? All employees providing your care have access to your health records. We will only provide information to other services with your consent or if required by law. These other services may include:

• Your General Practitioner (GP) • Your Maternal and Child Health Nurse • Specialist medical practitioners • Department of Health and Human Services.

In some circumstances QEC is obliged by law to release information from your health record, for example: • Presentation of your record as evidence in court when subpoenaed (e.g. in case of legal action) • Reporting of basic information about you to the Department of Health and Human Services, such as

age, gender and the suburb in which you live, but not your name • Reporting notifiable circumstances or diseases (e.g. some infectious diseases) to the Victorian

Department of Health and Human Services • Notification to our third party indemnity insurers in circumstances which may give rise to a claim.

Quality Improvement and Research At times files will be audited or checked to ensure that the information is accurate and complete. Your personal information is not collected or recorded during audits. The audits are conducted by employees or by an accreditation service, as required by our funding body. As necessary, de-identified information from health records may also be used for staff development, program reviews, future planning and evaluation. Information from your health record will only be used for research purposes with your consent and if the project has been approved by an ethics and research committee.

How can you gain access to information about you? In accordance with the Health Records Act 2001 (VIC) you have the right to request access to your health record. A fee may be charged for this service. If there is information in the record which is incorrect or with which you do not agree, you have the right to request that it be amended. Requests for access to your health record can be made in writing to: The QEC Privacy Officer - 53 Thomas Street Noble Park 3174.

Your Privacy

emihatTypewritten TextAppendix 2

emihatTypewritten Text

Updated December 2020. © QEC 2020 IT IS ILLEGAL TO REPRODUCE OR PHOTOCOPY THIS DOCUMENT WITHOUT WRITTEN PERMISSION


ADMINISTRATION USE ONLY Date Received UR No.

Phone Call: Completed

Date:

Attempted –Unsuccessful

Date:

Date:

Date:

Date:

Date:

Scheduled for later:

Day:

AM/PM:

Programs referred to: Residential Daystay Parenting Plus

Playsteps – Noble Park Gippsland S & S Advice

Telehealth Other (please specify):

NOTES:

Date Completed: Are you a parentcarer of a child less than 4 years of age: OffAre you experiencing challenges in relation to your childs sleep andor behaviour: OffAre you seeking information and support in addressing these concerns: OffSelf: OffHealth Professional please tick: OffName: Professional Role: Email: Phone Number: Please describe the main goal you would like QEC to help you with: ParentCarer 1First Name: ParentCarer 2First Name: Child 1First Name: Child 2 if applicableFirst Name: ParentCarer 1Surname: ParentCarer 2Surname: Child 1Surname: Child 2 if applicableSurname: ParentCarer 2DOB: Child 1DOB: Child 2 if applicableDOB: Ref no: Ref no_2: Ref no_3: Ref no_4: Expiry: undefined: Expiry_2: undefined_2: Expiry_3: undefined_3: Expiry_4: undefined_4: undefined_5: Offundefined_6: OffYes NoAddress: Yes NoAddress_2: Number if different from ParentCarer 1 Ref no Expiry Address: Number if different from ParentCarer 1 Ref no Expiry Address_2: Yes NoContact Number: Yes NoContact Number_2: Contact Email: undefined_7: Offundefined_8: Offundefined_9: Offundefined_10: OffSingle: OffDefacto: OffMarried: OffSeparated: OffSingle_2: OffDefacto_2: OffMarried_2: OffSeparated_2: OffSingle Married Defacto SeparatedCountry of Birth: Single Married Defacto SeparatedCountry of Birth_2: NACountry of Birth: NACountry of Birth_2: Single Married Defacto SeparatedYear of arrival if not born in Australia: Single Married Defacto SeparatedYear of arrival if not born in Australia_2: NAYear of arrival if not born in Australia: NAYear of arrival if not born in Australia_2: Single Married Defacto SeparatedWhat ethnicity do you identify with: Single Married Defacto SeparatedWhat ethnicity do you identify with_2: NAWhat ethnicity do you identify with: NAWhat ethnicity do you identify with_2: Single Married Defacto SeparatedLanguage spoken at home: Interpreter: OffIf Yes please specify what language: undefined_11: Offundefined_12: Offundefined_13: Offundefined_14: Offundefined_15: Offundefined_16: Offundefined_17: Offundefined_18: Offundefined_19: Offundefined_20: Offundefined_21: Offundefined_22: Offundefined_23: Offundefined_24: Offundefined_25: Offundefined_26: OffYear 910: OffVCE or equivalent: OffDiploma: OffDegree: OffMasters: OffLittle or no schooling: OffOther_5: OffYear 910_2: OffVCE or equivalent_2: OffDiploma_2: OffDegree_2: OffMasters_2: OffLittle or no schooling_2: OffOther_6: OffJobsearch: OffEmployed: OffFamily Assistance: OffSingle Parent Support: OffDisability Support: OffYoung Homeless: OffOther_7: OffJobsearch Employed Family Assistance Single Parent Support Disability Support Young Homeless Allowance Other: Reading: OffSeeing pictures and: OffBeing shown how to do: OffDoing it yourself: OffReading_2: OffSeeing pictures and_2: OffBeing shown how to do_2: OffDoing it yourself_2: OffPhone calls: OffSMS: OffWhatsapp video calls: OffFacetime: OffZoom video call app: Offundefined_27: OffOther please name: NameGP: NameMaternal Child Health: Phone NoMaternal Child Health: NameOther eg paediatrician psychologist psychiatrist: Phone NoOther eg paediatrician psychologist psychiatrist: NameOther: Phone NoOther: Yes No If yes: If yes: OffYes No If yes_2: If yes_2: OffYes No If yes_3: If yes_3: OffYes No If yes_4: If yes_4: OffYes No Details: Details: OffYes No Details_2: Details_2: OffYes No Details_3: Details_3: OffYes No Details_4: Details_4: Offundefined_28: Offundefined_29: Offundefined_30: Offundefined_31: Offundefined_32: Offundefined_33: Offundefined_34: Offundefined_35: Offundefined_36: Offundefined_37: Offundefined_38: Offundefined_39: Offundefined_40: Offundefined_41: Offundefined_42: Offundefined_43: Offundefined_44: Offundefined_45: Offundefined_46: Offundefined_47: Offundefined_48: Offundefined_49: Offundefined_50: Offundefined_51: Offundefined_52: Offundefined_53: Offundefined_54: Offundefined_55: Offundefined_56: Offundefined_57: Offundefined_58: Offundefined_59: Offundefined_60: Offundefined_61: Offundefined_62: Offundefined_63: Offundefined_64: Offundefined_65: Offundefined_66: Offundefined_67: Offundefined_68: Offundefined_69: Offundefined_70: Offundefined_71: Offundefined_72: Offundefined_73: Offundefined_74: Offundefined_75: OffYes No If Yes: If Yes: OffYes No If Yes_2: If Yes_2: OffYes No If Yes_3: If Yes_3: OffYes No If Yes_4: If Yes_4: OffGestational age at birth number of weeks: Baby weight at birth in grams: Childs current weight in grams: Good: OffAverage: OffPoor: OffGestational age at birth number of weeks_2: Baby weight at birth in grams_2: Childs current weight in grams_2: undefined_76: Offundefined_77: Offundefined_78: Offundefined_79: Offundefined_80: Offundefined_81: OffIf yes please list here: undefined_82: OffIf yes please list here_2: undefined_83: OffEvery day: Off34 daysweek: Off23 timesmonth: Offless often: Off56 daysweek: Off12 daysweek: Offabout 1 daymonth: OffNever: Offundefined_84: Offundefined_85: Offundefined_86: Offundefined_87: Offundefined_88: Offundefined_89: Offundefined_90: Offundefined_91: Offundefined_92: Offundefined_93: Offundefined_94: Offundefined_95: Offundefined_96: Offundefined_97: Offundefined_98: Offundefined_99: Offundefined_100: Offundefined_101: Offundefined_102: Offundefined_103: Offundefined_104: Offundefined_105: Offundefined_106: Offundefined_108: Offundefined_109: Offundefined_110: OffPlease provide any other relevant information: Your familys Maternal and Child Health Nurse If yes write name: Your doctor If yes write name: Your childs doctor If yes write name: Your childs Paediatrician If yes write name: Any other agencies or health professionals If yes write name: Check Box1: OffCheck Box2: OffCheck Box8: OffCheck Box9: Offundefined_107: OffCheck Box6: OffCheck Box7: OffCheck Box5: OffCheck Box3: OffPhone NoGP: Address 1: Address 2: Address 3: Address 4: Medicare 1: ParentCarer 1DOB: Medicare 2: Medicare 3: Medicare 4:

Private & Confidential REFERRAL FORM Referral...7. Give feedback. You can provide feedback or make a...

Documents

Transcript of Private & Confidential REFERRAL FORM Referral...7. Give feedback. You can provide feedback or make a...