Referral form

"*" indicates required fields

Step 1 of 6

16%

Referral details

Referral Date*

DD slash MM slash YYYY

Referrer's Name*

Referrer's first name Referrer's last name

Relationship to child*

Organisation*

Role/Title

Phone number*

Email address*

Parent/guardian have been made aware that Very Special Kids is a paediatric palliative care service and give consent to this referral*

Yes

Parent/Guardian have given verbal consent for Very Special Kids to access medical information, to guide eligibility to Very Special Kids*

Yes

Reason for referrral*

Change or deterioration in child's health

End-of-life care

Family exploring support services

Details

Has the child been registered with Very Special Kids previously?*

Yes

Unknown

Child Details

Child's name*

Child's first name Child's last name

Date of birth*

Day

Month

Year

Sex at Birth*

Male

Female

Indeterminate

Other/Prefer not to say

Gender identity*

Man, or boy, or male

Woman, or girl, or female

Non-binary

Transgender male (female to male)

Transgender female (male to female)

Prefer not to answer

Unknown/other

Preferred Language*

Other languages spoken at home:

Please list all if different for both parents/carers.

Interpreter required*

Yes

Aboriginal or Torres Strait Islander?*

Country of birth*

Child/family ethnicity

Culturally and linguistically diverse family*

Culturally and linguistically diverse (CALD) describes communities with diverse languages, ethnic backgrounds, nationalities, traditions, societal structures and religions. This may refer to people born overseas in non-English speaking countries, or people who identify with another culture or country.

Yes

Unsure

Child's address*

Street Address Address Line 2 City State / Province / Region Postcode Country

Child's condition*

Date of diagnosis*

DD slash MM slash YYYY

Is the child eligible for Medicare?*

Please note that eligibility for Medicare does not impact the ability for a child to access Very Special Kids services. This is only captured for compliance purposes.

Yes

Don't know

Child's medicare number

Number next to child's name on Medicare card

Childs name as written on Medicare Card

Does the child have access to the National Disability Insurance Scheme (NDIS)?*

Please note that eligibility for NDIS does not impact the ability for a child to access Very Special Kids services. This is only captured for compliance purposes.

Yes

Don't know

NDIS Number

Family Details

Parent/Guardian 1 name*

This should be the primary or number one contact for the child.

First Last

Relationship to child (1)*

Provide more information e.g. aunt, uncle

Parent 1 address*

Same as child's address

Street Address Address Line 2 City State Postcode Country

Parent 1 Phone number*

Parent 1 Email address*

Parent/Guardian 2 name

First Last

Relationship to child (2)*

Provide more information e.g. aunt, uncle

Parent 2 address

Same as child's address

Street Address Address Line 2 City State Postcode Country

Parent 2 Phone number

Parent 2 Email address

Child and home environment

Does the child live with family?*

Lives with family

Lives with others

What type of accomodation does the child live in?*

Who does the child reside with?*

Are there any legal/custodial issues*

Yes

Please provide details

Are there any risk factors we need to be aware of i.e. DV, substance abuse, protective issues etc.*

Yes

Please provide details

Siblings

How many siblings does the child have?

Sibling 1 Name

First Last

Sibling 1 Gender

Male

Female

Other

Sibling 1 Date of Birth

Day

Month

Year

Sibling 1 Age

If date of birth is unknown

Sibling 2 Name

First Last

Sibling 2 Gender

Male

Female

Other

Sibling 2 Date of Birth

Day

Month

Year

Sibling 2 Age

If date of birth is unknown

Sibling 3 Name

First Last

Sibling 3 Gender

Male

Female

Other

Sibling 3 Date of Birth

Day

Month

Year

Sibling 3 Age

If date of birth is unknown

Sibling 4 Name

First Last

Sibling 4 Gender

Male

Female

Other

Sibling 4 Date of Birth

Day

Month

Year

Sibling 4 Age

If date of birth is unknown

Sibling 5 Name

First Last

Sibling 5 Gender

Male

Female

Other

Sibling 5 Date of Birth

Day

Month

Year

Sibling 5 Age

If date of birth is unknown

Sibling details

Please provide name, gender and date of birth/age for each sibling

Are any of these children within the same family also diagnosed with a life-limiting condition that may be eligible for Very Special Kids?

Yes

Please provide details

Medical Details

Are you the child or young person's treating medical specialist?*

Yes

Treating Medical Specialist to complete

Treating medical specialist name*

First Last

Professional Speciality*

Phone Number*

Email address*

Contact address*

Street Address Address Line 2 City State Postcode Country

Child's primary diagnosis*

Other diagnosis or issues

Does this child meet one of the following groups?*

Group 1 - life-threatening conditions for which curative treatment may be feasible but can fail. Where access to palliative care services may be necessary when treatment fails e.g., cancer (usually solid tumours), irreversible organ failures of heart, liver and kidneys.

Group 2 - Conditions where premature death is inevitable, where there may be long periods of intensive treatment aimed at prolonging life and allowing participation in other activities (e.g. Duchenne muscular dystrophy).

Group 3 - Progressive conditions without curative treatment options, where treatment is exclusively palliative and may commonly extend over many years (e.g. Batten disease, mucopolysaccharidoses).

Group 4 - Irreversible, but non-progressive conditions causing severe disability leading to susceptibility to health complications and likelihood of premature death (e.g. severe cerebral palsy, neurodisability, birth injury, or an insult that follows an illness such as meningitis, encephalitis or head trauma).

None of the above.

Please indicate the vulnerability factors for this child or young person

Respitory

PICU admission for lower respiratory tract infection

Requirement for long term oxygen therapy or non-invasive ventilation at home

Tracheostomy and/or 24-hour ventilation

Feeding factors

Severe uncontrolled reflux despite maximum treatment

Losing weight due to feeding difficulties

Pain/distress associated with feeding, necessitating progressive feed reduction

Seizure related factors

Poor seizure control despite numerous drugs

Frequent use of rescue medication (daily basis)

Episodes of status epilepticus requiring intensive treatment (IV infusions / PICU)

Locomotor factors

Poor head control/fixed spinal curvature

Dependent on a wheelchair and unable to self-propel

Difficulty with maintaining sitting position (Gross Motor Function Classification System Level V)

Other neurological vulnerability to consider

Other evidence of severe bulbar involvement (worsening swallow, cough, gag reflex)

Baclofen pump (as a marker of severe hypertonia/very difficult spasms)

Severe visual impairment (registered blind)

VP shunt (particularly with frequent need of review)

In your considered opinion, is the child or young person likely to die in childhood (before age 18)*

Yes

Treating medical specialist details for contact

Treating medical specialist name*

First Last

Type of specialist*

Phone number*

Email address*

The treating medical specialist is aware of this referral, as they will be required to provide further medical information to determine eligibility.*

Yes

Hospital primarily accessed*

Royal Children's Hospital

Monash Children's Hospital

Other

Number of admissions in the past 12 months (approximately)

Care needs*

Psychosocial and other information*

i.e. family dynamics, support needs, mental health needs, behavioural support, child's care needs