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SLHD Child and Family Health Service Inquiry Form

SLHD Child and Family Health Service Inquiry Form

* Required Fields. Please submit your application by clicking the 'SUBMIT' button.

Please NOTE: Child and Family Health Services, Sydney Local Health District is NOT a 24/7, acute service. 

If you are worried about a deterioration of your mental or physical health, or that of the person you care for, see your GP or go straight to the emergency department at your nearest hospital, or call:

Emergency (Ambulance/ Fire/ Police) 000
Poisons Information 131126

If your queries are non-urgent, please proceed to complete the form. 

 

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Required Services

This online form is NOT for child developmental check booking - please call 02 9562 5400 for Child and Family Health Nurses.
 
Audiometry (hearing)
Orthoptic (vision)
Early Childhood Social Work (for parent/carer with children aged 0-3 years)
Child and Family Counselling
Nutrition/Dietetics
Speech pathology
Occupational therapy (OT)
Physiotherapy
Parent/carer
GP
Staff within SLHD
Other external health care worker/ professional like educator

Introduction

The next pages have questions about you and the child you want to refer to Child and Family Health Services. It will take 10-15 minutes to complete the form. If you have documents such as assessment reports, please have them ready to upload.

Upon completion, you can download a copy of the form or receive it via email for your records.

Filling out this form does not mean acceptance into our services. An intake officer may contact you to complete the process within two weeks. If you have any questions with the form, contact us at 02 9562 5400 (Monday to Friday, 8:30am to 4pm).

Yes     No

Important message for GPs:

DO NOT use this form for Community Paediatrics services referral.

Use the Sydney Local Health District HealthLink SmartForms - available through Best Practice, Genie, Medical Director or MyHealthLink Portal.

If you do not have a HealthLink account, sign up for free here.

For further information on SLHD eReferrals, see here.

For referrals to other Child and Family Allied Health services, please continue with the form below.

Important message for GPs:

DO NOT use this form for Community Paediatrics services referral.

Use the Sydney Local Health District HealthLink SmartForms - available through Best Practice, Genie, Medical Director or MyHealthLink Portal.

If you do not have a HealthLink account, sign up for free here.

For further information on SLHD eReferrals, see here.

For referrals to other Child and Family Allied Health services, please continue with the form below.

Yes   No
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Child's Details

Please enter your child's date of birth to view and complete the growth and development checklist at the bottom of the page.
This question is required.

Male
Female
Indeterminate
Yes
No
Not sure
Yes
No
Not sure
Yes
No
Not sure
Yes, Diagnosis has been made.
Yes, Diagnosis has been suggested/discussed.
No
Not sure
Yes, the child is accessing NDIS/ECA
Yes, the child is applying for NDIS/ECA
No
Not sure
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Parent/carer's Details

Yes
No
Not Sure
Yes
No
Yes
No
Yes
No
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About the child and the family

Please answer as many questions as you can.

Aboriginal but not Torres Strait Islander
Aboriginal and Torres Strait Islander
Torres Strait Islander but not Aboriginal
Neither Aboriginal nor Torres Strait Islander
Declined to Respond
Unknown
Currently living in Out of Home Care (OOHC), in kinship care or in a refuge
Have a history of/are at risk of harm, abuse or neglect
The child's caregivers have mental health concerns that impact on parenting
The child's caregivers are chronically or terminally unwell and this is impacting the child's wellbeing
Child and the family are asylum seekers or refugee
None of the above apply to the child
Not sure
Need paid work/more paid work
Are or at risk of becoming homeless
Do not have enough money to buy food needed for family
Do not have enough money to pay household bills (e.g. electricity, water)
None of the above apply to the child
Not sure

We ask all clients about their social situation to better understand the support they may need and to ensure we provide the most appropriate care for their overall well-being.

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About the child's growth and development

Please tick all the areas that the child can do.

If you're unsure, it's okay not to answer. You can also use the space below to share more information.

Calms down when spoken to or picked up
Looks at your face
Seems happy to see you when you walk up to them
Smiles when you talk to or smile at them
Makes sound other than crying
Reacts to loud sounds
Watches you as you move
Looks at a toy for several seconds
Holds head up when on tummy
Moves both arms and both legs
Opens hands briefly
Knows familiar people
Likes to look at themself in a mirror
Laughs
Takes turns making sounds with you
Blows "raspberries" (sticks tongue out and blows)
Makes squealing noises
Puts things in their mouth to explore them
Reaches to grab a toy they want
Closes lips to show they don't want more food
Rolls from tummy to back
Pushes up with straight arms when on tummy
Leans on hands to support themself when sitting
Plays games with you, like pat-a-cake
Waves "bye-bye"
Calls a parent "muma" or "dada" or another special name
Understands "no" (pauses briefly or stops when you say it)
Puts something in a container, like a block in a cup
Looks for things they see you hide, like a toy under a blanket
Pulls up to stand
Walks, holding on to furniture
Drinks from a cup without a lid, as you hold it
Picks things up between thumb and pointer finger, like small bits of food
Moves away from you, but looks to make sure you are close by
Points to show you something interesting
Puts hands out for you to wash them
Looks at a few pages in a book with you
Helps you dress them by pushing arm through sleeve or lifting up foot
Tries to say three or more words besides "muma" or "dada"
Follows one-step directions without any gestures, like giving you the toy when you say, "Give it to me"
Copies you doing chores, like sweeping with a broom
Plays with toys in a simple way, like pushing a toy car
Walks without holding on to anyone or anything
Scribbles
Drinks from a cup without a lid and may spill sometimes
Feeds themself with their fingers
Tries to use a spoon
Climbs on and off a couch or chair without help
Notices when others are hurt or upset, like pausing or looking sad when someone is crying
Looks at your face to see how to react in a new situation
Points to things in a book when you ask, like "Where is the bear?"
Says at least two words together, like 'More milk'
Points to at least two body parts when you ask them to show you
Uses more gestures than just waving and pointing, like blowing a kiss or nodding yes
Holds something in one hand while using the other hand; for example, holding a container and taking the lid off
Tries to use switches, knobs, or buttons on a toy
Plays with more than one toy at the same time, like putting toy food on a toy plate
Kicks a ball
Runs
Walks (not climbs) up a few stairs with or without help
Eats with a spoon
Calms down within 10 minutes after you leave them, like at a childcare drop off
Notices other children and joins them to play
Talks with you in conversation using at least two back-and-forth exchanges
Asks "who," "what," "where," or "why" questions, like "Where is mummy/daddy?"
Says what action is happening in a picture or book when asked, like "running," "eating," or "playing"
Says first name, when asked
Talks well enough for others to understand, most of the time
Draws a circle when you show them how
Avoids touching hot objects, like a stove, when you warn them
Strings items together, like large beads or macaroni
Puts on some clothes by themself, like loose pants or a jacket
Uses a fork
Pretends to be something else during play (teacher, superhero, dog)
Asks to go play with children if none are around, like "Can I play with Alex?"
Comfort's others who are hurt or sad, like hugging a crying friend
Avoids danger, like not jumping from tall heights at the playground
Likes to be a "helper"
Changes behaviour based on where they are (place of worship, library, playground)
Says sentences with four or more words
Says some words from a song, story, or nursery rhyme
Talks about at least one thing that happened during their day, like "I played soccer."
Answers simple questions like "What is a coat for?" or "What is a crayon for?"
Names a few colours of items
Tells what comes next in a well-known story
Draws a person with three or more body parts
Catches a large ball most of the time
Serves themself food or pours water, with adult supervision
Unbuttons some buttons
Holds crayon or pencil between fingers and thumb not a fist
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What are your concerns?

This section should outline your main concerns about the child and family, highlighting any new observations not previously mentioned. Also, suggest specific actions to take.

Client presentation summary:

  • Concerns: [Briefly state the main concerns]
  • Current symptoms: [List the clear, current symptoms and observations]

  • Relevant medical history
  • Current medication or any allergies
  • If the child has a diagnosed disability, developmental delay
  • Other services that the child has been referred to (current/past)

Relevant examination and investigation findings

E.g. "I believe the client is [brief description of the issue]. They are at risk of [briefly state risks] and need [briefly state needs]."


E.g. The client needs [actions/assessments] from [services] within [timeframe].
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Documents Upload and Feedback

Please upload any assessment/ report on the child's development or concerns, if you have them.

Note for SLHD staff: For existing client, please upload attachment/s directly onto eMR.

 
Required!
 

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Page Last Updated: 13 March, 2026