Melton City Council
Referral to Preschool Field Officer
Please note PSFO services are not available to children who are already receiving
Early Childhood Intervention Services (e.g. Noah’s Ark, Scope, Pinarc/Gateways, Specialist Children’s Services)
Parent/Guardian Section
Child’s Details
Child’s name
Address
Gender
Male
Female
Date of birth
Country of birth
Yes 
No 
Language/s spoken
Interpreter required
Is your child of Aboriginal or Torres Strait Islander descent?
No 
Does your child have any medical conditions? Yes 
No 
If Yes, specify?
Has your child had their vision checked?
Yes 
No 
Date
Outcome
Has your child had their hearing checked?
Yes 
No 
Date
Outcome
Yes, Aboriginal 
Has your child had their 3 and a half year old Maternal & Child Health check up?
Does your child have any siblings?
If Yes, what are their names and ages?
Yes 
Yes 
Yes, Torres Strait Islander 
No 
No 
Parent/Guardian Details
Child lives with
Both parents 
Mother 
Father 
Other ____________________________________
Parent/Guardian 1
Full name
Relationship to child
Country of birth
Home phone
Mobile phone
Email
Parent/Guardian 2
Full name
Relationship to child
Country of birth
Home phone
Mobile phone
Email
Kindergarten Details
Name of centre
Teachers
Email
Phone
Days & Times Child Attends
Monday
Tuesday
Wednesday
Thursday
Friday
AM
PM
Educator NonContact Times
Did your child attend a 3 year old kindergarten program
Yes  No 
If Yes, where?
What other organised activities does your child attend during the week
Your Concerns
Please outline any concerns you have for your child. Include any relevant information that may impact on your child and
attach any relevant documentation.
Other Agencies and Services Involved With the Family, Past and Present Who Can be Contacted
Regarding Your Child
Services
Name of Agency
Name of Professional
Contact Phone
Consent to contact
Speech Pathologist
Yes 
No 
Paediatrician
Yes 
No 
Psychologist
Yes 
No 
Occupational
Therapist
Yes 
No 
Hospital
Yes 
No 
Maternal and Child
Health Services
Yes 
No 
Family GP
Yes 
No 
Other
Yes 
No 
Must Be Completed By Referrer
Referrer Details
Who is making this referral?
Agency/Service  (If Agency, complete the below)
Agency Name
Contact Name
Phone
Email
Signature
Date
Parent/Guardian 
Developmental Details
Developmental Area
Self Care
e.g. feeding / dressing / toileting
etc. appropriate for age
Physical
e.g. gross and fine
motor skills such as moving around
/ crawling / walking / sitting, rolling,
using mobility aids etc.
Communication
e.g. understanding, talking and
communicating needs with others
appropriate for age, etc.
Relationships and Behaviour
e.g. relating to others within the
home or community environments
etc.
Learning and Play
e.g. learning, remembering and
practicing new skills such as
playing games, pretend play, etc.
Concerns
Describe the concerns regarding the child’s
development
Impact
Describe how this substantially impacts on
the child’s daily living activities and
participation in family and community life
Educator Section
Educator Information
What is the main reason for referral?
What strategies are you currently using to work with this child?
Must Be Completed By Parent/Guardian
Parent/Guardian Declaration
I, _________________________________________________, a person with lawful authority of the child referred to in
this form, have read the information written on this form, and give permission for the Preschool Field Officer (PSFO) to
observe my child in the kindergarten setting. I consent to the exchange of relevant information (written and verbal)
about my child with the kindergarten staff, any relevant agencies, and/or future enrolled educational settings.
I understand that this is to assist in supporting my child and develop a consistent program and strategies to meet my
child’s individual needs within the kindergarten setting.
Signature Parent/Guardian 1
Date
Signature Parent/Guardian 2 (if applicable)
Date
Privacy Statement
Melton City Council is collecting the personal and health information on this form for the purposes of enabling the Preschool Field
Officer to work with your child. The information will only be disclosed to the Kindergarten Teacher, Preschool Field Officer; other
agencies listed on this form (where you have given consent) and in some instances with other Council children’s services staff.
The information will not be disclosed to any other party unless required by law. Parents or Guardians are able to access their child’s
file at any time. If you have any queries or concerns about providing this information, please contact the Preschool Field Officer on
9747 7200 to discuss further.
Please return this completed form together with any additional pages/information as required to:
Preschool Field Officer Service
City of Melton
PO Box 21
MELTON VIC 3337
Or scan and email to:
psfo@melton.vic.gov.au
If you have any queries or need to discuss this form you can contact the PSFO on 9747 7200.
Office Use Only
Date received ______________
Client Code ______________
Checked by Intake _______
Confirmation Letter Date ______________