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Home › Early Childhood › Referral

Referral

Use this form to record information about a child aged 0 to 6 years with developmental delay or disability who is seeking support through the NDIS.

Step 1 of 12

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Parents and carers:

After talking with your child's health or educational professional our early childhood partners can help you connect to the right supports. You do not need a referral or diagnosis from a medical professional to access support through our early childhood approach.

If you require support to complete this referral you can contact us on 1300 012 293.

Educators and professionals:

When completing this form, we will ask you if families are informed and agree to this referral. This includes discussing the developmental information that you will provide to Meli.

Please note that if it is unclear whether a child meets the developmental criteria for access to the NDIS it is likely that a period of Early Supports will be offered prior to this step.

Educators and professionals can arrange a secondary consultation and/or request a referral form by calling 1300 012 293.
Eligibility – NDIS

Part 1 – General Information about ECEI

Please use this form to record information about a child aged under seven years with developmental delay or disability who is seeking support through the National Disability Insurance Scheme (NDIS).
What is ECEI?
Early Childhood Early Intervention (ECEI) is funded by the NDIS. ECEI can offer a range of supports for eligible children under seven years.
What is the aim of ECEI?
The aim of ECEI is to provide parents and families with the knowledge, skills and support to optimise their child’s development and ability to participate in family, early childhood education and care settings, and in broader community life.
Who can benefit from ECEI?
A child aged under seven years who has either:
- a developmental delay which is the result of an impairment and causes substantial functional limitations and who requires a coordinated, multidisciplinary service response; or
- a disability; and
- lives in the Barwon Region.
The Early Childhood Partner’s role
- The first contact point for families of children aged under seven years seeking support through the NDIS.
- To determine with families/carers the most appropriate supports that would benefit and achieve outcomes for your child, tailored to their individual needs and circumstances;
The types of supports provided by an Early Childhood Partner are:
- Information
- Referral to mainstream or community services;
- Short term early intervention supports; and
- Where required, assistance to access the NDIS.
How to complete and submit this form
This form may be completed by:
- a family or carer, with the assistance of a professional
- a professional working with the family/carer such as a GP, paediatrician
Steps to complete and lodge this form:
Complete the ECEI referral to Early Childhood Partner form and record parent/ carer/ guardian/ child representative consent.

If consent is provided by the parent/ carer/ guardian/ child representative, please attach copies of any relevant assessments, reports or letters from health professionals that describe the child’s needs in support of this information form where appropriate.

Further information regarding ECEI can be found at the following website: NDIS Website, ECEI Page or email ecei@bcyf.org.au or phone 1300 012 293.

Part 2 – ECEI Information Gathering

This information assists the Early Childhood Partner to learn more about the child. Please provide information where appropriate and as agreed to by the child’s family, carer or guardian.

Please read consent and privacy information on pages 8 through to 12 and seek signed consent where indicated.
Child Details
Child’s first name*
Child’s surname*
Date of birth*
Please note this service is for children aged 0-7. If your child is 7 years or older, please contact the NDIS on 1800 800 110.
DD slash MM slash YYYY
Gender*
Centrelink Customer Reference Number (CRN)
Is the child an Australian citizen?
- Yes
- No
Is the child of Aboriginal or Torres Strait Islander origin?
- Yes
- No
If Yes, please specify*
- Aboriginal
- Torres Strait Islander
- Aboriginal & Torres Strait Islander
Does the child live with parents?*
- Yes
- No
Does the child live with others?
- Yes
- No
If Yes, please provide details*
Country of birth*

Parent / Carer Details
Adult number 1 name*
First Last
Date of birth
DD slash MM slash YYYY
Relationship to child*
(e.g. mother, father, grandparent)
Home address*
Street Address City State Post Code Country
Is Adult number 1 of Aboriginal or Torres Strait Islander origin?
- Yes
- No
If Yes, please specify
- Aboriginal
- Torres Strait Islander
- Aboriginal & Torres Strait Islander
Contact Number*
Email*
Preferred Language*
Preferred contact
(e.g. phone, letter, email)

Adult number 2 name
First Last
Date of birth
DD slash MM slash YYYY
Relationship to child
(e.g. mother, father, grandparent)
Home address
Same as previous

Street Address City State Post Code Country
Is Adult number 2 of Aboriginal or Torres Strait Islander origin?
- Yes
- No
If Yes, please specify
- Aboriginal
- Torres Strait Islander
- Aboriginal & Torres Strait Islander
Contact Number
Email
Preferred Language
Preferred contact
(e.g. phone, letter, email)

Custody / Court Orders
The Early Childhood Partner needs to understand the environment that the child lives in and who best to contact about your child. This includes knowing about existing parenting, custody or guardianship arrangements.
Are there any existing parenting, custody or guardianship arrangements for the child?*
- Yes
- No
If yes, please specify?*
Language / Interpreter
Main language spoken at home*
Is an interpreter required for a phone conversation?*
- Yes
- No
Child’s Disability and / or Developmental Delay
Does the child have a diagnosed disability?*
- Yes
- No
If Yes, please indicate the diagnosis*
Does the child have a developmental delay?*
- Yes
- No
If No, is the child undergoing assessment for developmental delay of disability?*
- Yes
- No
Please provide details of the professional who made the diagnosis or is undertaking the child’s assessment.
Name
Profession
Organisation name and address
Phone Number
Email
Additional information
(i.e. recent hospitalisation, starting school soon etc.)

Details of Professional helping complete this form

Details of the professional completing / assisting with this information form (if any).

The Early Childhood Partner may need to contact the professional listed below to better understand your child’s circumstances and to ensure that your child is connected to the supports that best meet their needs.
Name
First Last
Position / Title
Service
Phone
Mobile
Email
Address
Street Address Address Line 2 City State Post Code Country
Signature

Additional Professionals / Services

Please list the services and supports you are already using to help meet your child’s needs (e.g. GP, paediatrician, maternal & child health nurse, medical specialist, therapist etc.) and the services your child currently attends (e.g. childcare, kindergarten, occasional care etc.)

The Early Childhood Partner may need to contact the people that you list to better understand your child’s circumstances and to ensure that your child is connected to the supports that best meet their needs.
Additional Professional/Service 1
Service name
Professional
Address
Street Address City State Post Code Country
Do we have your permission to contact this Professional / Service and share your child’s information to better understand their circumstances?
- Yes
- No
Additional Professional/Service 2
Service name
Professional
Address
Street Address City State Post Code Country
Do we have your permission to contact this Professional / Service and share your child’s information to better understand their circumstances?
- Yes
- No
Additional Professional/Service 3
Service name
Professional
Address
Street Address City State Post Code Country
Do we have your permission to contact this Professional / Service and share your child’s information to better understand their circumstances?
- Yes
- No

Details of Developmental Delay
Please ensure consent from family / carer / guardian prior to completing this section.
Self-Care (e.g. feeding / dressing / toileting etc. appropriate for age)
Concerns
Describe the concerns regarding the child’s development
Impact
Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
Physical (e.g. gross and fine motor skills such as moving around / crawling / walking / sitting, rolling, using mobility aids etc.)
Concerns
Describe the concerns regarding the child’s development
Impact
Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
Communication (Language and Speech) (e.g. understanding, talking and communicating needs with others appropriate for age, etc.)
Concerns
Describe the concerns regarding the child’s development
Impact
Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
Relationships and Behaviour (e.g. social, skills, relating to others within the home or community environments etc.)
Concerns
Describe the concerns regarding the child’s development
Impact
Describe how this substantially impacts on the child’s daily living activities and participation in family and community life
Cognitive (Learning and Play) (e.g. learning, remembering and practicing new skills such as playing games, pretend play, etc.)
Concerns
Describe the concerns regarding the child’s development
Impact
Describe how this substantially impacts on the child’s daily living activities and participation in family and community life

Previous Assessments / Additional Information
Please discuss with the family / carer / guardian the opportunity to attach copies of documents that describe the child’s needs that may support this information form. This is an option they may choose. The relevant documents may include medical assessment and reports, letters, screening assessments from health and/or educational professionals, court orders or other relevant parent/guardian/carer documents.
Previous Assessments / Additional Information
Please provide the detail of any assessments that the child has received (e.g. Hearing, Vision), or any additional information that may be relevant.
Supporting documents
Drop files here or

Max. file size: 10 MB, Max. files: 5.

Part 3 – Important Privacy Information

Please read this section carefully. If you have any questions, contact ECEI on ecei@bcyf.org.au
Barwon Child, Youth & Family Privacy Policy
- Barwon Child, Youth & Family (BCYF) is committed to ensuring the privacy and confidentiality of its clients.
- We collect, manage and protect your personal information in line with privacy legislation and are guided by the Australian Privacy Principles, which regulate how we collect, use, hold and share your personal information.
What is personal information?
- Personal information is any information which identifies you. For example, your name, date-of-birth, nationality or heritage, home address and telephone number.
- Personal information may also include information about your racial origin, religious beliefs, sexual preferences, criminal record and information about your health.
What kinds of personal information do we collect and hold?
- We keep your name and contact details on a client record.
- Other details such as plans, notes and other important information are also recorded.
Why do we collect and hold your information?
- The information we collect helps us to keep up-to-date details about your needs, so we can provide you with the best possible service and support.
- We only collect and record information that we need to support you.
View full BCYF privacy policy

Parent / Carer Consent
- I have read and understood the General Information (Part 1) and the Important Privacy Information (Part 3) provided with this information form.
- I understand how my child’s personal information will be collected, used and disclosed for the purposes of the NDIS, which is set out in Part 3 of this information form.
- I have carefully read all of the information provided in the information form and confirm that it is accurate, complete and up to date.
- I consent to Barwon Child, Youth & Family collecting, using and disclosing personal and sensitive information about my child in accordance with the General Information and Important Privacy Information sections in this document.
- I understand that I may withdraw consent to receive support from an ECEI service provider at any time.
- I give permission to contact the professional completing / assisting with this information form (if any).
Signed*
Parent / Carer / Guardian*
- Parent
- Carer
- Guardian
Date*
DD slash MM slash YYYY
Verbal Consent Received
- Yes
- No
If yes, Please provide details*
Date*
DD slash MM slash YYYY
Supporting documents
Drop files here or

Max. file size: 10 MB, Max. files: 5.
Your Name*
Send a copy of completed referral form to referrer
Consent*
I consent to a copy of my completed referral form to be sent to the email address entered above.*

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We acknowledge that we work and connect on the traditional and unceded lands of Aboriginal peoples and pay our respects to their Elders past and present.

We are committed to the reconciliation journey through our actions and openness to learn.

Meli is committed to creating an environment where everyone feels safe and that they belong.

We welcome people of all races, ethnicities, genders, sexual orientations, ages, religions, abilities and nationalities and value diversity of experience as a vital part of supporting people and strengthening communities.

We will listen, learn and evolve as an accessible, inclusive and safe organisation for all, including First Nations peoples, members of the LGBTQIA+ community, people with a disability and those with culturally diverse backgrounds.

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BCYF & Bethany have merged! Our two like-minded not-for-profit organisations are now Meli. We’re working together to strengthen our community through all stages of life. In the meantime, you can continue to access all BCYF and Bethany services and programs at bcyf.org.au and bethany.org.au.

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