QEC Referral Form

QUEEN ELIZABETH CENTRE

53 Thomas Street

Noble Park

www.qec.org.au

(03) 9549 2777
Welcome to QEC

The Queen Elizabeth Centre (QEC) is Victoria’s largest Early Parenting Centre.
Our Vision is for children to get the best start in life.
We provide advice and a range of programs aimed at supporting parents in their parenting journey.

Our team is here to connect you to the program that is most suitable to your needs and goals. Making a referral is the first step.

We support families with children newborn to their 4th birthday.

QEC accepts referrals from parents/carers and professionals.
Referral Form
- Referral Reason (Multiple Choice)*
  
  My child's sleep and settling patternsFeeding my child : Breast/Bottle feedingFeeding my child solidsUnderstanding my child’s behaviourUnderstanding and strengthening my relationship with my childStrengthening my parenting skillsFeeling socially isolated and needing more supportAdjusting to parenthoodOther
- Tick the box that describes how much help are you currently getting with the above?*
  
  A lotSomeVery littleNone
- Any additional information you would like to share with us? *
- Have you made a referral to another EPC ?*
  
  NoYes
- If Yes, Name of the EPC
- Have you participated in a QEC program within the last 3 months?*
  
  YesNo
- This form is being completed by*
  
  SelfHealth Professional
- How did you hear about us?
- How did you hear about us?*
  
  Health ProfessionalFamily or friendCommunity word of mouthSocial MediaInternet search
- **Disclaimer: Not all referrals will be triaged into an EPC program**
  
  QEC has close partnerships and regular contact with other Early Parenting Centres (EPC) across Victoria.
  
  The Victorian Early Parenting Centres are all working together to ensure you get the support you need as soon as possible.
- Do you consent to being contacted if a program becomes available at another Victorian EPC at short notice?*
  
  YesNo
- Do you consent to your information being shared with this EPC?*
  
  YesNoN/A
- Health Professional Name*
  
  First NameLast Name
- Health Professional Service Name*
- Profession*
- Phone Number*
  e.g. 11183021
- Health Professional Email*
- Parent / Carer #1 Full Name*
  
  First NameLast Name
- Parent / Carer #1 Date of Birth*
  
  DayMonthYear
  Date
- Parent / Carer #1 Email*
  example@example.com
- Parent / Carer #1 Sex (assigned at birth)*
  
  MaleFemaleIndeterminateOther
- Indigenous Status*
  
  Aboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalNeither Aboriginal nor Torres Strait IslanderBoth Aboriginal and Torres Strait IslanderPrefer not to answer
- Gender*
  
  Man, or boy, or maleWoman, or girl, or femaleNon-binaryDifferent termPrefer not to answer
- Marital Status*
  
  SingleDefactoMarriedSeparatedWidowed
- Phone Number*
  Please enter a valid phone number.Format: 0000000000.
- Country of Birth*
- Parent / Carer #1 - If not born in Australia, year of arrival in Australia*
- Parent / Carer #1- Language spoken at home*
- Parent / Carer #1 - Do you need an interpreter? If yes, What language?*
- Parent / Carer #1 - What ethnicity do you identify with?*
- Parent / Carer #1- Any accessibility support required? if yes, what support ?*
- Parent / Carer #1 - Are you an NDIS Participant ?*
  
  NoYes – new NDIS participant during this admission,Yes – existing NDIS prior to admission,Not stated
- Parent / Carer #1 -What is your NDIS Participant Identifier ?*
  Only Numeric
- Parent / Carer #1 Address*
  
  Street Address
  
  Street Address Line 2
  
  Suburb / CityState
  
  Post codeCountry
- Do you have Private Health Insurance?*
  
  YesNoPrefer Not To Say
- If yes, which health fund are you with?
- Will another Parent be admitted to the program?*
  
  YesNo
- Name of emergency contact *
- Mobile Number*
  Please enter a valid phone number.Format: 0000000000.
- Relationship to Parent/Carer #1 *
- Parent / Carer #2 Full Name*
  
  First NameLast Name
- Parent / Carer #2 Date of Birth*
  
  DayMonthYear
  Date
- Parent / Carer #2 Email*
  example@example.com
- Parent / Carer #2 Sex (assigned at birth)*
  
  MaleFemaleIndeterminateOther
- Indigenous Status*
  
  Aboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalNeither Aboriginal nor Torres Strait IslanderBoth Aboriginal and Torres Strait IslanderPrefer not to answer
- Gender*
  
  Man, or boy, or maleWoman, or girl, or femaleNon-binaryDifferent termPrefer not to answer
- Marital Status*
  
  SingleDefactoMarriedSeparatedWidowed
- Phone Number*
  Please enter a valid phone number.Format: 0000000000.
- Country of Birth*
- Parent / Carer #2 - If not born in Australia, year of arrival in Australia*
- Parent / Carer #2- Language spoken at home*
- Parent / Carer #2 - Do you need an interpreter? If yes, what language?*
- Parent / Carer #2- What ethnicity do you identify with?*
- Parent / Carer #2 - Any accessibility support required? if yes, what support?*
- Parent / Carer #2- Are you a NDIS Participant?*
  
  NoYes – new NDIS participant during this admission,Yes – existing NDIS prior to admission,Not stated
- Parent / Carer #2 -What is your NDIS Participant Identifier ?*
  Only Numeric
- Is Parent / Carer #2 Address same as Primary Carer?*
  
  YesNo
- Parent / Carer #2 Address*
  
  Street Address
  
  Street Address Line 2
  
  Suburb / CityState
  
  Post codeCountry
- Child Full Name*
  
  First NameLast Name
- Date of Birth*
  
  DayMonthYear
  Date
- Indigenous Status*
  
  Aboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalNeither Aboriginal nor Torres Strait IslanderBoth Aboriginal and Torres Strait IslanderPrefer not to answer
- Gender*
  
  Man, or boy, or maleWoman, or girl, or femaleNon-binaryDifferent termPrefer not to answer
- Country of Birth*
- If not born in Australia, year of arrival in Australia*
- What ethnicity does your child identify with?*
- Any accessibility support required? if yes, what support ?*
- Is your Child a NDIS Participant?*
  
  NoYes – new NDIS participant during this admission,Yes – existing NDIS prior to admission,Not stated
- Child #1 What is your NDIS Participant Identifier ?*
- Is Child Address same as Primary Carer ?*
  
  YesNo
- Child Address *
  
  Street Address
  
  Street Address Line 2
  
  Suburb / CityState
  
  Postal / Zip CodeCountry
- Will you require our services for a second child?*
  
  YesNo
- Second Child Full Name*
  
  First NameLast Name
- Second Child - Date of Birth*
  
  DayMonthYear
  Date
- Second Child - Indigenous Status*
  
  Aboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalNeither Aboriginal nor Torres Strait IslanderBoth Aboriginal and Torres Strait IslanderPrefer not to answer
- Second Child - Gender*
  
  Man, or boy, or maleWoman, or girl, or femaleNon-binaryDifferent termPrefer not to answer
- Second Child - Country of Birth*
- Second Child - If not born in Australia, year of arrival in Australia*
- Second Child - What ethnicity does your child identify with?*
- Second Child - Any accessibility support required? if yes, what support?*
- Second Child - Is your Child a NDIS Participant?*
  
  NoYes – new NDIS participant during this admission,Yes – existing NDIS prior to admission,Not stated
- Second Child - What is your NDIS Participant Identifier ?*
  Only Numeric
- Is Second Child Address same as Primary Carer?*
  
  YesNo
- Second Child Address *
  
  Street Address
  
  Street Address Line 2
  
  Suburb / CityState
  
  Postal / Zip CodeCountry
- Will you require our services for a third child?*
  
  YesNo
- Third Child Full Name*
  
  First NameLast Name
- Third Child - Date of Birth*
  
  DayMonthYear
  Date
- Third Child - Indigenous Status*
  
  Aboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalNeither Aboriginal nor Torres Strait IslanderBoth Aboriginal and Torres Strait IslanderPrefer not to answer
- Third Child - Gender*
  
  Man, or boy, or maleWoman, or girl, or femaleNon-binaryDifferent termPrefer not to answer
- Third Child - Country of Birth*
- Third Child - If not born in Australia, year of arrival in Australia*
  
  DayMonthYear
  Date
- Third Child - What ethnicity does your child identify with?*
- Third Child - Any accessibility support required? if yes, what support?*
- Third Child - Is your Child a NDIS Participant?*
  
  NoYes – new NDIS participant during this admission,Yes – existing NDIS prior to admission,Not stated
- Third Child - What is your NDIS Participant Identifier ?*
  Only Numeric
- Is Third Child Address same as Primary Carer?*
  
  YesNo
- Third Child Address *
  
  Street Address
  
  Street Address Line 2
  
  Suburb / CityState
  
  Postal / Zip CodeCountry
- My Healthcare Rights and Privacy - Please access QEC website for your rights and privacy information
- I confirm that I have read "My Healthcare Rights" and Privacy Information*
- Please verify that you are human*
- Should be Empty: