Early Childhood Referral Form

Use this form to record information about a child under nine years of age seeking support through Brotherhood of St Laurence who has:

a developmental concern
a developmental delay, or
a disability

What is the early childhood approach?

The early childhood approach is funded by the NDIS. The early childhood approach can offer a range of supports for eligible children under nine years.

What is the aim of the early childhood approach?

The early childhood approach aims to support parents and families by:

Building knowledge and skills
Providing support to meet their child's needs
Maximising their child's development
Increasing participation in family life, early childhood education and care settings, and the broader community

The early childhood partner’s role

The first point of contact for families of children aged under nine years seeking support. Working alongside families and carers to identify the most appropriate supports to help their child achieve their goals and outcomes.

An early childhood partner can support families through

Early supports for children and families
Information and guidance about child development
Connections with peer and family networks
Access to mainstream and community services
Assistance to access the NDIS where appropriate

Finding the right early childhood partner

BSL Early Childhood supports children and families in:

North-East Melbourne (Banyule, Darebin, Nillumbik, Whittlesea, Yarra)
Bayside Peninsula (Bayside, Frankston, Glen Eira, Kingston, Mornington Peninsula, Port Phillip, Stonnington)
Hume Merri-bek (Hume, Merri-bek)
Brimbank Melton (Brimbank, Melton)
Western Melbourne (Hobsons Bay, Maribyrnong, Melbourne, Moonee Valley, Wyndham)

If your child lives outside these areas, call 1800 800 110 or check the NDIS Office Locator to identify the most appropriate Early Childhood Partner.

Do You Need More Information?

For more information about the NDIS Early Childhood Approach, visit the NDIS Early Childhood Approach page on the NDIS website or call the BSL on 1300 275 634.

If you are using a screen reader, use the Pagination Menu to navigate between pages, or use the Tab key and arrow buttons to move to the Next or Previous page.

How to complete this form

Please complete this form if you are referring a child under nine years of age who may benefit from Early Childhood supports.

Please provide as much information as possible. If you are unsure about a question, provide the best information available.

This referral includes:

Referrer contact details
Child details
Parent or legal guardian details
Current supports and services
Areas of concern
Supporting documents
Parent or legal guardian consent

Before you submit:

Ensure parent or legal guardian consent has been completed.
Attach any relevant supporting documents if available.
Check that contact details have been entered accurately.

Please note:

Do not upload identity documents such as passports, birth certificates or driver's licences.
Documents with encrypted passwords cannot be opened through this form.

Need help?

If you require support completing this form, or need to provide password-protected documents, please email BSL.CustomerService@ndis.gov.au

Section A: Contact Details

Please provide details of the person completing this referral form.

This information will be used to identify who submitted the referral and send a copy of the completed referral to the email address provided.

Please specify your role or relationship to the child: *

Please specify your relationship to the child: *

Has consent been obtained from the parent or legal guardian for this referral to be submitted? *

YesNo

Date of referral:

Organisation making referral:

Full name: *

Email: *A copy of the completed referral will be sent to this email address.

Parent/Legal Guardians email:A copy of the completed referral will be sent to this email address so the child's parent or legal guardian is aware of the referral.

Key contact person: *

Phone number: *

Office address: *

Section B: Child's Details

This section may be completed either the referrer or the parent or legal guardian of the child being referred.

Please ensure all required fields are completed and the child's details are entered accurately to avoid delays.

Child's first name: *

Child's middle name:

Child’s last name: *

Has the child ever used, or been known by another name? *

YesNo

Please list the child's previous name: *

Date of birth: *

Gender: *

Please specify: *

Preferred pronouns: *

Please specify *

Country of birth: *

Is the child of Aboriginal and/or Torres Strait Islander origin? *

Is the child an Australian citizen?

YesNo

Does the child hold a Permanent Residency Visa or a Protected Special Category Visa?

YesNo

Please provide details of the child's current visa, including the visa subclass (if known):

Who does the child live with?

Preferred language used at home: *

Address: *

Street address *

Suburb *

State *

Postcode *

Is this address the same as your postal address?

YesNo

Provide postal address:

Preferred communication style *

Has the child started school?

YesNo

Does the child have a parent, sibling, or other immediate family member accessing NDIS or Early Childhood Supports?

YesNo

Provide the family member's NDIS number or full name:

Are there any court orders, parenting orders, guardianship arrangements, or other legal arrangements relating to the child's care or decision-making? *

YesNo

Please specify the type of court order or legal arrangement: *

Please attach the relevant documentation to Section F of this form.

Does the child have a diagnosis? *

YesNo

Provide the child's diagnosis:

Details of the professional who completed the diagnosis:

Section C: Parent or Legal Guardian Details

Please ensure you complete all required fields and ensure details are accurate to avoid delays.

If there is more than one parent or legal guardian involved, please provide details for each person where possible.

What is your relationship to the child? *

Please specify your relationship to the child

First name: *

Middle name:

Last name: *

Have you ever used, or been known by another name? *

YesNo

Please provide your previous name: *

Date of birth: *

Gender: *

Please specify: *

Preferred pronouns: *

Please specify your preferred pronouns: *

Country of birth: *

Address: *

Street address *

Suburb *

State *

Postcode *

Is this address the same as your postal address?

YesNo

Provide postal address:

Are you of Aboriginal and/or Torres Strait Islander origin? *

Contact number: *

Email: *

Preferred communication style: *

Preferred language used at home: *

Is an interpreter required? *

YesNo

What type of interpreter is required? *

Would you like to opt in to receive NDIA feedback surveys? *

YesNo

The NDIA uses feedback surveys to understand people's experiences with the NDIS. Further information is available on the NDIS website.

Consent:

The person who completed Section A is referring the child for Early Childhood supports. Do you consent to the Brotherhood of St Laurence sharing information about the child's referral with that person? *

YesNo

Which information can be shared with the person who completed Section A? *

How long are you giving consent for? *

Consent end date: *

Do you consent to the Brotherhood of St Laurence contacting the person who completed Section A to collect information about the child if required? *

YesNo

How long are you giving consent for? *

Consent end date *

Additional Parent or Legal Guardian Details (Optional)

Would you like to add details for a second parent or legal guardian? *

YesNo

What is your relationship to the child? *

Specify your relationship to the child

First name: *

Middle name:

Last name: *

Have you ever used, or been known by another name? *

YesNo

Please provide your previous name: *

Date of birth: *

Gender: *

Please specify: *

Preferred pronouns: *

Please specify your preferred pronouns:

Country of birth: *

Address: *

Street address *

City *

State *

Postcode *

Is this address the same as your postal address?

YesNo

Provide postal address:

Are you of Aboriginal and/or Torres Strait Islander origin? *

Contact number: *

Email: *

Preferred communication style: *

Preferred language used at home: *

Is an interpreter required? *

YesNo

What type of interpreter is required? *

Opt in to receive NDIA feedback surveys *

YesNo

The NDIA uses feedback surveys to understand people's experiences with the NDIS. Further information is available on the NDIS Website.

Section D: Key Contacts - Other Services or Supports

If you are working with an organisation, you may wish to give them consent to be contacted as part of the referral process.

To do this, please provide details for at least one key contact in the organisation below. You can nominate up to two key contacts in total.

If your key contacts change, please let us know so we can update who in the organisation you have given consent to.

If you do not wish to nominate an organisation contact, select Next to proceed to Section E.

First name:

Last name:

Profession or relationship:

Organisation name:

Phone number:

Email:

What consent are you providing for this organisation?

Additional Key Contact Details (Optional)

Would you like to add details for a second key contact?

YesNo

First name:

Last name:

Profession or relationship:

Organisation name:

Phone number:

Email:

What consent are you providing for this organisation?

Section E: Areas of concern with child's development

Please provide any information about areas where the child may be experiencing difficulties or needs extra support.

Include specific examples where possible. Please ensure consent is received from the child’s parents or legal guardians before completing this section.

Please note: Each field below has a maximum limit of 800 characters (approximately 130 words).

If you need to provide more information that can be accomodated within this limit, please attach a separate docment and include it in Section F: Supporting Evidence and Documentation.

Physical:

For example, gross and fine motor skills such as crawling, walking, sitting, rolling, using hands and fingers, or using mobility aids.

Provide details:

Cognitive:

For example, learning, remembering and practising new skills, such as playing games, engaging in pretend play, and participating in everyday activities.

Provide details:

Communication:

For example, understanding, expressing and communicating needs with others.

Provide details:

Social/Emotional:

For example, developing social skills and relating to others at home, at school, or in community settings.

Provide details:

Self care:

For example, everyday self-care activities such as feeding, dressing, toileting, sleeping and grooming.

Provide details:

Provide any additional information:

Section F: Supporting Evidence and Documentation

Please upload any documents that may help us understand the child's circumstances, support needs, or the reason for referral.

This may include, but is not limited to:

Reports or assessments from health, education, or community services
Relevant diagnoses or medical information
Therapy or intervention reports
Court, custody, guardianship, or parenting orders
Other documents that provide useful background information

Please note:

Do not upload identity documents (such as passports, birth certificates, or driver's licences) as part of this referral. Any identity documents submitted will not be retained.
Identity documents, if required, can be provided at a later stage.
Please be aware that we may not be able to open documents with Encrypted Passwords. If documents you wish to submit have an Encrypted Password, please email us directly to BSL.CustomerService@ndis.gov.au

Upload Supporting Documentation and Evidence:

Browse

Section G: Parent or Legal Guardian Consent

This section must be completed by the parent or legal guardian of the child being referred. If this section is not completed, we will be unable to proceed with the referral.

Need to obtain a signature?

If you are completing this referral on behalf of a parent or legal guardian, use the Save for later button and send the referral to the parent or legal guardian to complete this section and provide their signature.
If the parent or legal guardian is unable to sign electronically, print this page (Section G) and obtain a handwritten signature. The signed page can then be uploaded in Section F or emailed to BSL.CustomerService@ndis.gov.au

Do you use assistive technology or keyboard navigation to complete online forms? *

YesNo

By signing this form:

I have read and understood the General Information and Important Privacy Information provided with this referral form.
*

I understand how my child's personal information will be collected, used and disclosed for NDIS purposes.
*

I confirm that the information provided in this referral form is accurate, complete and up to date.
*

I consent to Brotherhood of St Laurence collecting, using and disclosing personal and sensitive information in accordance with the General Information and Important Privacy Information sections.
*

I understand that I may withdraw my consent to receive support from an Early Childhood Partner at any time.
*

I give permission for Brotherhood of St Laurence to contact the professional(s) listed in Section A if required.

Parent or Legal Guardian signature: *

Clear

Parent or Legal Guardian signature: *

Draw signature|Type signatureClear

What is your relationship to the child? *

Parent or Legal Guardian name: *

Date signed: *

Save and Complete Later