Connected Beginnings Program

Referral Form

IWC’s Connected Beginnings Program is a culturally responsive program that uses a holistic model of care approach to support the health, wellbeing and development of First Nations children from 0 to 5 years of age, to be healthy & developmentally ready for school.

Our Connected Beginnings Team, inclusive of an Endorsed Midwife and Indigenous Health Worker will work alongside participants and families to facilitate access and support to appropriate services and activities that focus on the needs of participants and families. These may be provided either individually or group based.

Support and services are focused on strengthening jarjums in key areas that support their health and development in all stages of early childhood, ensuring their ability to learn and thrive as they move towards being ready for school.

The Connected Beginnings Team will ensure connection with the participant’s General Practitioner as a key health professional within the jarjum’s life, to ensure provision of appropriate care and pathways are engaged and facilitated as determined, that support improved health & development milestone outcomes for the participant.

Participant Details

Full Name
Address
Date of Birth	Age in years
Gender	​​☐ Female	​​☐ Male
Participant Identifies as	​​☐ Aboriginal	​☐ Torres Strait Islander	​☐ Aboriginal & Torres Strait Islander	☐ Other

Parent/Guardian Details

Please mark	Parent	Guardian
Full Name
Address
Contact Phone Number
Contact Email Address

Participant’s General Practitioner

Doctor Name
Medical Centre Name
Street Address
Suburb	State	Post Code
Phone

Referring Details

Please tick who is completing the referral form, from the options below

Parent/Guardian
Internal Service (please complete below Internal Referral Details)
External Service (please complete below, Referring Agency Details)

Internal Referral Details (To be completed if Internal Service)

Service Area	Medical	Allied Health	Social Health & Wellbeing
Referrer Name
Referrer Position
Signature	Date Signed

Referring Agency Details (To be completed if External Service)

Agency Name
Street Address
Suburb	State	Post Code
Referrer Name
Referrer Position
Phone	Fax
Email
Signature	Date Signed

Reason for referral

Please provide a brief description of the reason for referring the above-mentioned child to the Connected Beginnings Program.

Assessment

To support understanding the child’s current health, wellbeing & development, has the child had a First Nations Health Assessment in the last 9 months?

YES	NO
​​☐​	​​☐​

If yes, to the above,

Approximate date Health Assessment was conducted ?

Please advise which practice this was conducted at?

Program Activities & Services

Please advise what services within the Connected Beginnings Program you are most interested in the child being supported in.

Services
First Nations Health Assessment Support or advocacy to facilitate the child having an up to date First Nation’s Health Assessment through the child’s GP.
Case Management Service access & attendance Individual referral and services pathways Holisitc Case Management
Focused Education Sessions Developed & targeted education sessions on child health, wellbeing, and development topics.
Group Activities & Connection Coming together, connecting, learning, and growing with each other.
Patient Education & Information Tailored resources on specific topics to improve child health, wellbeing, and development.

Depending on the program services marked above, the participant may need to visit their usual GP for further care, preparation of assessments, plans, or referrals.

Declaration

I declare the above information is true and correct and has been completed with the parent(s)/guardian(s) consent and or by the parent/guardian of the participant.

Name
Signature	Date