BEHAVIOUR, LEARNING AND DEVELOPMENT REFERRAL
NORTH WEST PAEDIATRIC SERVICES (NWPS)	

The North West Paediatric Services offers an interdisciplinary service to children aged 0-18 years requiring input from paediatric medicine and or allied health. The referral will be directed to the most appropriate services required to meet the needs of the child	

Referrer Details	
Date: <<Miscellaneous:Date>>	
Referrer name (print): <<Doctor:Name>>	
Practice name: <<Practice:Name>>	
Address: <<Doctor:Address Line 1>>, <<Doctor:City>>, <<Doctor:Postcode>>	
Email: <<Doctor:E-mail>>	Phone:  <<Doctor:Phone>>	

Patient Details	
Interpreter/Support Services Required: <<Interpreter/ Support Services required?>>  If yes, language: <<If yes, language:>>	
Identifies as Aboriginal or Torres Strait Islander: <<Identifies as Aboriginal or Torres Strait Islander?>> 	 If yes, Aboriginal Liaison Officer required: <<If yes, Aboriginal Liaison Officer required?>>	
Interpreter booked		Aboriginal Health Liaison Officer booked		Face to face		Phone/Telehealth		
First name (print): <<Patient Demographics:First Name>>	
Family name: <<Patient Demographics:Surname>>	
Preferred name (print):  	
Date of Birth: <<Patient Demographics:DOB>>	Gender: <<Patient Demographics:Gender>>	
Address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>	
Email: <<Patient Demographics:E-mail>>	Phone: <<Patient Demographics:Phone (Mobile)>>	
Indigenous Status: <<Patient Demographics:ATSI>>	
Parent/Guardian/ Agency name: <<Parent/Guardian/ Agency name:>>:  	
Relationship to client:  <<Relationship to client:>>	

Primary Reason for Referral [X]	
	Need to Establish diagnosis, Treatment or intervention	
	Requesting advice/management	
	Requesting a specialist to take over management	
	For specified test/investigation that a GP can’t order or the patient can’t afford to access	
	Other reason for example, rapidly accelerating disease progression	
If you consider this referral urgent, please explain:
<<If you consider this referral urgent, please explain>>	

Diagnosis confirmed/provisional	
Description of concerns – include relevant medical and developmental history – see Health Pathways for relevant assessments/screening:
<<Description of concerns include relevant medical hx>>	

behaviour in preschoolers    behavioural concerns 6-12 years  development concerns in children  ADHD in children and young people  autism spectrum disorder  speech and language difficulties in children  plagiocephaly  poor growth in children	
Concerning features for example, definite history of developmental regression? Child to be in out of home care for greater than 6 months? Or placement at risk?

Family History	
<<Family history:>>

<<Clinical Details:Family History>>	

Previous Testing	
Vision: <<Previous vision test?>>	Hearing: <<Previous hearing test?>>	Child Health Checks: <<Previous child health checks?>>	
Other: (attach any info if you have it)
<<Other previous tests? (attach any info if you have it)>>	
Current investigations: 
<<Current investigations:>>	

Current/previous supports/intervention
Note: children with behavioural concerns under 6 years must have been referred for parental support programs before being referred to NWPS	
<<Current/ previous supports/ interventions:>>	

Supporting documentation:
Children attending school presenting with behavioural/ learning difficulties must have supporting documentation from school included	
<<Supporting documentation:>>	

Does the parent/guardian provide consent to contact other agencies involved in the child’s care for school, childcare for further relevant information/ reports?  <<Consent>>
Please list appropriate contacts:
<<Please list appropriate contacts:>>	

North West Paediatric Services provide an integrated service for children aged 0-18 years incorporating paediatric medicine, nursing and allied health.  To access any discipline, simply make a referral to the service as a whole and it will be reviewed at an interdisciplinary intake meeting.  In some instances when deemed clinically appropriately, a referral may be directed to allied health or nursing support or an alternative community-based service.
NWPS provides assessment and diagnostic services, interdisciplinary monitoring of health-related conditions and short term, goal directed allied health support.  If a child or family requires longer term support, they will be assisted to access a more appropriate service. Children with an NDIS or ECEI plan that require support to address issues that are covered by their plans should be directed to their NDIS service provider. Children requiring speech pathology and educational psychology support to access their educational curriculum should contact their school for support.	
Abbreviation key: ECEI Early Childhood Early Intervention  	NDIS National Disability Incentive Scheme