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Development act. gov.au Client Referral New Issue Form Please give send fax or email to Child Development Service. Act. gov.au Work Ph Name of Client Reason for Referral please describe in detail If referrer is not the parent/guardian then complete the following REFFERER INFORMATION Referrer Name Referrer Role e.g. class teacher network coordinator Referrer Phone contact Referrer Address Suitable contact time Has consent for this referral been obtained from client parent or guardian TPP 5 Privacy Notice CSD is obliged to handle your information openly transparently and in accordance with the Territory Privacy Principles set out in the Information Privacy Act 2014. We explain how we collect use share and store your personal information and how you can access and correct it in our privacy policy. You can view our privacy policy at www. communityservices. act. gov.au. If you fill in this form your personal information will be collected and handled by us. Child Development Service Intake Service Cnr Weingarth St and Blackwood Tce Holder ACT 2611 Phone 02 6205 1246 Fax 02 6205 1266 Email Child. PLEASE PROVIDE THE FOLLOWING CLIENT INFORMATION Name Date of Referral DOB Indigenous Status Male Female Aboriginal Country of Birth Torres Strait Islander Aboriginal Torres Strait Islander Living Arrangements e*g* with family group home Neither Aboriginal nor Torres Strait Islander Address Suburb Postcode Home Ph Mobile Other Email Preferred Language Interpreter Required Yes No Diagnosis if known Education Setting if appropriate Class Medications if known Past Present Other Relevant Agencies Involved ESSENTIAL INFORMATION Please provide Parent/Guardian details Relationship to client Address if different from above ACT GOVERNMENT GPO Box 158 Canberra ACT 2601 ACT Government Homepage http //www. act. gov*au Work Ph Name of Client Reason for Referral please describe in detail If referrer is not the parent/guardian then complete the following REFFERER INFORMATION Referrer Name Referrer Role e*g* class teacher network coordinator Referrer Phone contact Referrer Address Suitable contact time Has consent for this referral been obtained from client parent or guardian TPP 5 Privacy Notice CSD is obliged to handle your information openly transparently and in accordance with the Territory Privacy Principles set out in the Information Privacy Act 2014. We explain how we collect use share and store your personal information and how you can access and correct it in our privacy policy. You can view our privacy policy at www. communityservices. act. gov*au. If you fill in this form your personal information will be collected and handled by us. This information is necessary for us to provide you with services and support. If you do not consent to supply us with this information we may not be able to satisfactorily assist you or your child. CSD will not use or disclose this information for another purpose without your consent unless you would reasonably expect us to use or disclose the information for a related purpose or it is required by another law.

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