Children’s Health Queensland Hospital and Health Service Child Health Service Referral	(Affix patient identification label here)
CHQ clinicians can now submit digital referrals via qhRefer. Please consider submitting a digital referral instead of completing this form. Information for CHQ clinicians is available at https://qheps.health.qld.gov.au/childrenshealth/html/health-informatics/qhrefer Has this referral been discussed with the child’s Legal Guardian? Yes No CHILD DETAILS Family name: Given name: Date of birth: Gender: Preferred name: Address: Country of birth: Indigenous status: Aboriginal Torres Strait Islander Not stated/unknown Aboriginal AND Torres Strait Islander NOT Aboriginal or Torres Strait Islander Is the child of South Sea Islander descent? Yes No Alerts / allergies: PARENT, LEGAL GUARDIAN OR APPROVED FOSTER CARER DETAILS Legal Guardian: Parent/s Other: Parent / Guardian family name: Given name: Date of birth: Address (if different to child’s address): Suburb: Postcode: Home phone: Mobile: Interpreter required? Yes No Preferred language: REFERRAL INFORMATION Presenting concern and Parent or Legal Guardian’s goals: Relevant medical history: Relevant developmental history: Parent / carer / family psychosocial history: OTHER KEY CONTACTS Other agencies / therapy services involved: REFERRING AGENT DETAILS Name: Position: Organisation: Address: Phone: Email: Date: Click or tap to enter a date. External to Queensland Health please consider the Privacy Obligations for secure sending of Health Information. Please FAX your completed form to: 07 3139 6555 Queensland Health staff can submit a referral by: Saving form as a PDF Emailing the completed PDF to CHQ-CH-Referral@health.qld.gov.au Or printing and faxing to (07) 3068 3719

CHQ Referral enquiries – PH: 1300 245 126 More information: https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/child-health-service/