CASEY.VIC.GOV.AU
Preschool Field Officer
Support Request Form 2015
CHILD’S DETAILS
Name of Child:
Date of Birth:
(
/
/
Male/
Female)
Country of Birth:
Language spoken at home:
Address:
Suburb:
Postcode:
Parent / Guardian Name:
(
Male/
Female)
(
Male/
Female)
Phone: (H)
Mobile:
Email:
Country of Birth:
Parent / Guardian Name:
Phone: (H)
Mobile:
Email:
Country of Birth:
Does the child live with both parents:
Yes
No
Address (if different from parent/guardian signing this form):
Suburb:
Postcode:
Brothers and sister’s names and ages:
Interpreter required?
Is the child Aboriginal?
Yes
Yes
No
Language spoken:
No
Is the child a Torres Strait Islander?
Yes
SERVICE DETAILS
Kindergarten/Centre Name and Address:
Contact Number:
Educator’s Names:
Child’s attendance times:
______________________ _____________
Email: _____________________
_____________ __________________
_____
_________
No
TEACHER TO COMPLETE (Attach more paper if needed)
What strengths have you noticed in the child recently?
What are your reasons for referral? Please list any developmental areas of concern at kindergarten.
What strategies have you implemented? Have they been effective?
TEACHER TO COMPLETE IN CONSULTATION WITH THE CHILD
I feel happy when
I feel sad when
I feel angry when
I feel scared when
I feel worried when
Please Note: If a child is nonverbal or does not respond verbally to your consultation, please
document his/her reaction/body language.
PARENT / GUARDIAN TO COMPLETE (Attach more paper if needed)
Please answer the following questions to provide Preschool Field Officers with a better
understanding of your child and their individual needs:
Has your child had their 3.5 year old Maternal and Child Health Check
Yes
No
What skills has your child learnt recently, and what are their strengths?
What concerns do you have regarding your child’s development, if any?
What strategies have you implemented? Have they been effective?
Is there anything occurring in your family at the moment that may be affecting your child’s
behaviour?
Does your child make use of any other services or agencies:
Speech Therapist
Family Day Care
Pediatrician
Long Day Care
Occupational Therapist
Early Childhood Intervention Service
Behavioural Ophthalmologist
Other
Diagnosed Disability (if applicable):
I give permission for the Preschool Field Officer to contact other Children’s Services within
the City of Casey and the agencies listed below to exchange relevant information (written
and verbal) about my child. I understand that this is to assist in developing a consistent
program and strategies to meet my child’s individual needs.
Yes
No
Agencies my child is supported by
Contact Person
I give permission for the Preschool Field Officer to observe my child in the kindergarten
setting and exchange information with the kindergarten staff. I understand that this is to
assist in supporting my child’s individual needs within the kindergarten setting.
Parent/Guardian name
Signature
Date
Privacy Statement
Your personal information will be handled in accordance with the Privacy and Data Protection Act 2014 and used
for the specified purpose. You can access your personal information by contacting Council’s Privacy Officer on
9705 5200.