Referral Form

Please complete this form to register for our services.

Childs First Name *


Childs Preferred Name


Childs Last Name *


Date of Birth *
Calendar

Gender *


Parent/Guardian First Name *


Parent/Guardian Last Name *


Name of person completing this form and Relationship to Child *


Parent/guardian Mobile *


Parent/guardian Email *


Contact details for secondary contact (if applicable). Please include full name, phone number and email address *


Client Address *


State *


Postcode *



Therapy Services you would like to join *

WT - Hanen TalkAbility
WT - Hanen More than Words
WT - It Takes Two to Talk
WT - Speech Pathology
WT - OT Assessment only
WT - Dietitian
WT - Autism Assessment
WT - Speech Path Assessment
WT - Occupational Therapy (OT)
WT - Music Group
WT - Therapy Assistant
WT - Fun With Food Group
WT - Intensive Therapy
WT - School Readiness Program



Appointment Preferences *


Preferred Days
Mon  Tue  Wed  Thu  Fri

Preferred Time


Preferred Location


Preferred Contact Method *
Email Phone Text Any



NDIS & Funding


NDIS funding *
Yes, child has funding No, child doesn't have funding In application process


NDIS number


Plan start date


Plan end date


NDIS report




Fund management *
Self-managed Plan-managed



Family Information


Please list all people living in the house by name, age, and relationship to child *


Primary language spoken at home (please advise if you will require an interpreter) if not English


List of services that the child is currently engaging with or has engaged with (including names, disciplines ie. OT or Speech Pathology) and contact details


Please check below if there are any current or past legal proceedings and/or Court Orders involving the child


If you have ticked above, please provide details of these legal proceedings and/or Court Orders



Child Development


Has this child received a formal diagnosis? (eg. autism, genetic condition, global developmental delay etc.). *
Yes No


If yes, please provide as much information as possible regarding the diagnosis including age of child at the time and person responsible for diagnosis.


What concerns do you have for this child that has led you to seek therapy supports? *
Speech (eg. speech clarity) Language (eg. understanding and use) Social communication (eg. friendships) Self-care skills (eg. toileting) Motor skills (eg. fine and gross motor) Behaviour / stress response Emotional Regulation Feeding (eg. diet range, chewing)


If you selected 'other' above, please explain briefly


Please list any concerns you have relating to this child's speech, language and comprehension


Please list any concerns you have relating to this child's movement, balance and grip


Please list any concerns you have relating to this child's sleep and toileting


Please list any concerns you have relating to this child's eating (diet, chewing etc.)


What are your priorities and expectations regarding therapy? *


Please use the space below to provide further information about this child that you feel may be necessary or useful


Please choose your preferred location/s for appointments *
Home Early Child Education Centre / In Clinic


Please select EACH statement below to confirm you agree and acknowledge that you have read and agree to the following conditions. If you do not select each of the following conditions, this response will be deleted, and no further action will be taken.


I understand and acknowledge that:


Information will be shared between Dot to Dot Early Intervention and authorised contacts/professionals nominated by you (e.g. Paediatrician, childcare workers or schools). *


My information will be shared within the Dot to Dot Early Intervention team on a professional basis only, who will work together to develop an individualised program for your child. *


All reasonable steps are taken to keep your personal information confidential, and your details will not be used for marketing or any other purposes without your permission. *


Dot to Dot Early Intervention reserves the right to refuse services if there is abuse of any kind toward a staff member, another client or any person associated with our services. This includes if any person fears for their safety or for any other reason which need not be disclosed. *


Dot to Dot is proud of its multicultural team. Our team members perform at Australian standards with recognised degrees and experience. If at any point you have concerns regarding your therapist's accent please contact our Practice Manager, Stacey Brighton directly via email: stacey.brighton@d2d.net.au or ph: 0480 476 378. *




We will do our best to contact you as soon as possible. 

Wait times could vary however it is anticipated there would be a 6 to 8 month wait for Speech Pathology. 

We may text you periodically to see if you still want to remain on our waitlist. Once a position becomes available, we will contact you. Please keep us informed of any changes that may affect your services and ensure our records are kept up to date. 

We look forward to working with you.