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The Kids Hub Referral Form
Company
This field is for validation purposes and should be left unchanged.
Please note, we are not a crisis service. If crisis assistance is required, please call Access Mental Health on 02 6205 1065 or emergency on 000.
The Kids Hub provides a range of free mental health and wellbeing services for children aged 0–12 years, as well as their families, carers and kin. When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.
Referral details
1. Referrer source
(Required)
Self-Referral
GP / Paediatrician
Other service
2. Referrer name
(Required)
Enter your name
3. Service name
(Required)
Enter your answer
4. Phone number
Enter your answer
5. Email
(Required)
Enter your answer
6. The child must meet all of the following:
(Required)
Live and/or study in the ACT
Be between the ages of 0–12 years
Be experiencing mental health difficulties
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Child information
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7. Full name
(Required)
Enter your answer
8. Preferred name
Enter your answer
9. Date of Birth
Month
Day
Year
10. Address
Street
Address Line 2
City
State
Post Code
11. Gender
Girl
Boy
Non-binary
I do not wish to specify
Other
12. Country of birth
Australia
Other
13. Interpreter required
Yes
No
14. Proficiency in English
Very well
Well
Not well
Not at all
15. First Nations status
Aboriginal
Torres Strait Islander
Both Aboriginal and Torres Strait Islander
Neither
16. Refugee and asylum seeker status
Refugee
Asylum Seeker
Both Refugee and Asylum Seeker
Neither
17. Culturally and linguistically diverse background?
Yes
No
18. Does the child or parent identify as LGBTQIA+?
Yes
No
19. Does the child have a disability or chronic illness?
Yes
No
20. Is the child on an NDIS plan?
Yes
No
21. Main language spoken at home
Enter your answer
22. Other details, if applicable
Enter your answer
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Parent/Guardian 1
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23. Name
(Required)
Enter your answer
24. Relationship to child
(Required)
Enter your answer
25. Phone number
Enter your answer
26. Can we leave a voice message?
Yes
No
27. Email address
Enter your answer
28. Is this parent/guardian aware of the referral?
Yes
No
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Parent/Guardian 2
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29. Name
Enter your answer
30. Relationship to child
Enter your answer
31. Phone number
Enter your answer
32. Can we leave a voice message?
Yes
No
33. Email address
Enter your answer
34. Is this parent/guardian aware of the referral?
Yes
No
Current services being accessed
35. Current services being accessed
CAMHS
CYF
Allied Health Support
Counselling Support
Other
36. What services have been provided, and what goals or identified needs are they addressing?
Enter your answer
37. Reason for referral
What has brought you to the Kids Hub today? (Select all that apply)
Mental health concerns
Emotional difficulties/regulation
Behavioural concerns
Social engagement
Academic/school difficulties
Trauma/Grief/Adjustment challenges
Family or environmental stressors
Developmental concerns
Requiring information/referral options
Other
38. Please explain in further detail for your visit to the Kids Hub:
Enter your answer
Consent
Parent/guardian has been informed of the Kids Hub service and understands the information provided in this referral is required to determine their eligibility for services. Parent/guardian is willing to participate in sessions (group and/or individual) to support the child towards best outcomes.
39. Referrer/Parent/Guardian confirmation
Yes
No
Privacy
(Required)
Please read our
Privacy Policy
before submitting this form.
I have read and agree to the Marymead CatholicCare Canberra & Goulburn Privacy Policy.
