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Latrobe Regional Gallery

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Families
Agency Referral Form: Enhanced Maternal and Child Health

Agency Referral Form: Enhanced Maternal and Child Health

Agency only: use this form to refer clients to Council's Enhanced Maternal and Child Health program.

Referral Details

Request Type

Referrer Agency

Referrer Name

Referrer Contact Number

Copy of completed referral to be emailed to:

EMCH Program Support

The EMCH program works with children and families to address an increased need due to factors currently impacting on child development, parenting capacity, or family wellbeing.

In order to be eligible for the program the family need to meet two or more of the below eligibility criteria. Please mark which ones are relevant

Mother/parent is less than 20 year of age

Infant/child is identified as being an Aboriginal or Torres Strait Islander descent and is not actively attending the UMCH program

Family is socially isolated (housing, cultrual group, transport, unemployment)

Mental health issue currently impacting parenting capacicty

Parent expresses and/or demonstrates poor attachment towards their infant/child

Substance abuse related issues currently impacting parenting capacity

Family violence currently impacting safety, parenting and infant/child development

Current intervention from Child Protection

Infant/child born with congenital abnormalities

Infant/child born with complex growth, health and development issues

Concerns on the part of the assessing nurse

Families who are not currently engaged with the UMCH program

Family has consented referral to EMCH

Program has been explained to the client

Children Details

Referred Child Full Name

Referred Child Date of Birth

Mother's Details

Mother's Full Name

Mother's Date of Birth

Mother's Address

Mother's Phone Number

Mother's Cultural Background

Is mother aboriginal or Torres Strait Islander?

Mother's Language

Is an interpreter required for mother?

Father's Details

Father's Full Name

Father's Date of Birth

Father's Address

Father's Phone Number

Father's Cultural Background

Is father aboriginal or Torres Strait Islander?

Father's Language

Is an interpreter required for father?

Parent Details

Are there any court order/custody arrangements in place?

If yes, provide details of court order/custody arrangements

Primary Care Giver's Details (if different to details above provided for Mother and/or Father)

Primary Care Giver's Full Name

Primary Care Giver's Date of Birth

Primary Care Giver's Address

Primary Care Giver's Phone Number

Agency Support

Which agencies are involved?

Child Protection

Child FIRST

PASDS

Support and Safety Hub

Family Violence Service

GP or Paediatrician

Psych Service (CAT)

Mental Health Service

Disability Services

Housing Services

Koori Maternity Service

VACCA

CALD Service

Drug and Alcohol Services

No agency involvement

Unknown

Other…

Enter other…

Details of supports currently in place and agency involvement

Any other Relevant Information/Recommendations:

Other information

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Contact Us

Contact Details

Phone: 1300 367 700

Email: latrobe@latrobe.vic.gov.au

Acknowledgement

We acknowledge the Traditional Custodians of the land, the Brayakaulung people of the Gunaikurnai nation. We pay our respects to their Elders past, present and emerging.