smalltalk Supported Playgroup online referral form

smalltalk Supported Playgroup Referral Form

The smalltalk program is delivered across the Bendigo region by a qualified facilitator in a supported playgroup or in-home coaching setting. This form is for both referrers and those who are self-referring.

Referrer details

Note: If you are self-referring please do not fill this section out.

Name

First Last

Organisation

Phone

Date of referral

Reason for referral

Referral questions

Note: Self-referrers and Referrers must fill this section out.

Has the family consented to this referral?(Required)

Yes

Has the smalltalk program been discussed with the family?(Required)

Yes

Does the family want to engage with:(Required)

Supported Playgroup

In-home coaching

Both

How will the smalltalk program benefit the family?(Required)

Are there any barriers that may impact the client engaging or attending?(Required)

Parent details

Name(Required)

Prefix First Last

Pronouns

Date of birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Cultural background(Required)

Emergency contact name(Required)

Relationship to parent(Required)

Phone number(Required)

Do you identify as an Aboriginal or Torres Strait Islander?(Required)

Yes

Prefer not to say

What is the main language spoken at home?(Required)

Is an interpreter required?(Required)

Yes

If yes, please state the language required:

Child/ren details

Please note: For families with more than one child, please fill out details for all children who will be in contact with our smalltalk facilitator.

Child 1 name(Required)

First Last

Country of birth(Required)

Date of birth(Required)

Medical / disability information(Required)

Child 2 name

First Last

Country of birth

Date of birth

Medical / disability information

Child 3 name

First Last

Country of birth

Date of birth

Medical / disability information

Other information

If you have other information you would like to share with our smalltalk facilitator please do so below.

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Acknowledgement of Country

Bendigo Community Health Services acknowledge we live, work and enjoy Dja Dja Wurrung and Taungurung country. We extend our appreciation to the Jaara and Taungurung peoples. We pay respect to Elders past and present for their continued holding of memories, traditions, culture and community aspirations.

We recognise sovereignty has never been ceded and express our sorrow for the personal, spiritual and cultural costs of colonisation and their lasting impact. May we walk forward together in harmony and the spirit of healing. It was and always will be Aboriginal land.

Image credit: Healing a Community by Paige Charles-Morgan

Acknowledgement of Country

Image credit: Healing a Community by Paige Charles-Morgan

Bendigo
Central

165-171 Hargreaves Street

Now open for our women’s, men’s and sexual health clinics on a strictly ‘appointment only’ basis. Call 5406 1200 if you have a question.

Hours and services

Kangaroo
Flat

19 Helm St, Kangaroo Flat

Phone: 03 5406 1200
Fax: 03 5441 4200

Hours and services

Elmore

46 Jeffrey St, Elmore

Phone: 03 5406 1558
Mob: 0408 333 014

Hours and services

North
Bendigo

137a Holdsworth Road, North Bendigo

Phone: 03 5406 1200

White
Hills

501a Napier Street, White Hills

Phone: 03 5406 1200

Hours and services

Eaglehawk

3 Seymoure Street, Eaglehawk

Phone: 03 5406 1200

Hours and services

Bendigo
Central

165-171 Hargreaves Street

Now open for our women’s, men’s and sexual health clinics on a strictly ‘appointment only’ basis. Call 5406 1200 if you have a question.

Hours and services

Kangaroo
Flat

19 Helm St, Kangaroo Flat

Phone: 03 5406 1200
Fax: 03 5441 4200

Hours and services

Elmore

46 Jeffrey St, Elmore

Phone: 03 5432 6001
Fax: 03 5432 610

Hours and services

North
Bendigo

137a Holdsworth Road, North Bendigo

Phone: 03 5406 1200

Hours and services

White
Hills

501a Napier Street, White Hills

Phone: 03 5406 1200

Hours and services

Eaglehawk

3 Seymoure Street, Eaglehawk

(Currently closed for refurbishment)
Phone: 03 5406 1200

Hours and services

Disclaimer

We monitor the quality of the information available on this website and regularly update our content and information. We may amend, delete, add to, or otherwise revise any information or materials at any time without notice. It is your responsibility to monitor for any such changes.

Diversity and inclusion commitment

We support people to develop and maintain their personal, gender, sexual, cultural, religious and spiritual identity.

smalltalk Supported Playgroup Referral Form

Referrer details

Referral questions

Parent details

Child/ren details

Other information

Acknowledgement of Country

Acknowledgement of Country

Our locations

Bendigo Central

Kangaroo Flat

Elmore

North Bendigo

White Hills

Eaglehawk

Bendigo Central

Kangaroo Flat

Elmore

North Bendigo

White Hills

Eaglehawk

Disclaimer

Diversity and inclusion commitment

Bendigo
Central

Kangaroo
Flat

North
Bendigo

White
Hills

Bendigo
Central

Kangaroo
Flat

North
Bendigo

White
Hills