Primary School Nursing Program Student Referral Form printable pdf download

Primary School Nursing Program Student Referral Form

Primary School

Nursing Program

Student Referral Form

The Primary School Nursing Program accepts referrals for children in grades 1 – 6, children attending English Language

Centre Schools and primary school-aged children who have recently arrived in Australia from overseas.

If you or your child’s teacher has concerns about your child’s health or development, your child can be referred to the

school nurse at any time using this referral form.

Direct health assessment services provided under the Primary School Nursing Program may include:

• Vision screening

• Hearing screening

• Mouth check

• Speech and language screening

• General developmental assessments

A health assessment under the Primary School Nursing Program is not intended to replace your normal source of health

care.

If you agree to have your child’s health assessed by a school nurse, please:

• read the Information privacy statement (Section B)

• sign the Parent Consent (Section C)

• complete Your Child’s Personal Details (Section D)

• return this completed form to the school in the supplied envelope.

Section A

To be completed by the TEACHER prior to sending the Referral Form to the Parent/Guardian

Please note that it is essential that you discuss this referral with the child’s parent/guardian before providing the referral

form to them.

Have you discussed the reason for referral with the child’s parent/guardian?

Yes

To be completed by the TEACHER

Reason for referral

I would like to refer your child for a direct health assessment:

Child’s name

Year Level

Room No.

Reason for Referral

Comments regarding:

Academic Progress

Social Development

Has this child been referred to any other agency or health professional?

Yes

If Yes, please specify

Teacher’s Name (Please Print)

Date

Primary School Nursing Program Student Referral Form