CHILD
DEVELOPMENT
UNIT
WOMEN’S & CHILDREN’S HOSPITAL
1st Floor, Rieger Building
72 King William Road, North Adelaide SA 5006
Tel: (08) 8161 7287
Fax: (08) 8161 6099
Email: CYWHSCDUSecretary@health.sa.gov.au
WCH CDU REFERRAL FORM
Our aim
To provide a team approach to the assessment and management of children whose development is of concern in
two or more areas and to provide support to their families.
What services do we offer?
Developmental assessment of children with two or more difficulties such as:
 slow development
 speech and language problems
 problems with their physical activities
 forming friendships with other children
 sensory processing.
Explanation of the assessment results and recommendations are offered to parents, teachers and other involved
professionals. Discussion with parents regarding the involvement of or referral to other community agencies which
may provide a more suitable treatment program. Appointment of a ‘contact person’ who will act as a key worker for
parents and monitor services provided. Review the progress of children if required.
Who can refer to CDU?
Medical Professionals (General Practitioners,
Paediatricians, Medical Officers, Specialists)
Please note** If a child is referred to the Unit by
the areas listed below the CDU process can
begin. However a Paediatric Appointment will
not be allocated until a GP referral is provided.
 Allied Health Professionals
 Care/Education via Leadership Team in
consultation with Support Services eg. Speech
Pathology, Psychology or DECD Special
Educator, Catholic Education / Association of
Independent Schools SA Special Education
Consultants/Advisors.

Acceptance of referrals is subject to catchment
areas which are defined for the three assessments
units
 Child Assessment Team, Flinders Medical
Centre, Tel: 8204 4433
 Gordon McKay Child Development Unit, GP
Super Clinic Elizabeth, Tel: 7485 4094
 Child Development Unit, Women’s and
Children’s Hospital, Tel: 8161 7287
If you are unsure of the appropriate Unit, please call
the number above for assistance.
WCH CDU REFERRAL FORM
* Mandatory Information – if this information is not provided it may hold up the processing of this application.
**MEDICAL PROFESSIONALS ONLY**
DEAR DR
☐WHITE ☐TIDEMANN ☐JEYASEELAN ☐O’KEEFE ☐BAULDERSTONE ☐ NOZZA ☐ GALLUS
CHILD *
Surname
Given Names
DATE OF BIRTH *
SEX *
Male Female
WCH UR NO:
CHILD’S ADDRESS *
Town
PARENTS *
State
Mother
Postcode
Father
ADDRESS *
IF DIFFERENT FROM CHILD’S
Town
State
Postcode
Town
State
Postcode
TELEPHONE *
Home
Mobile
Home
Mobile
LEGAL GUARDIAN * (if other)
MEDICARE NO
-
-
Child ID Number
Expiry Date
PROFESSIONAL REFERRING*
DATE OF REFERRAL *
/
/
REFERRAL
LENGTH
PROVIDER NO
If Medical Professional
☐12MONTHS
☐INDEFINITE
If Medical Professional
AGENCY & POSITION *
ADDRESS *
Town
Work
State
Fax
Postcode
Mobile
TELEPHONE *
EMAIL ADDRESS *
SIGNATURE
☐YES ☐NO
Is Parent/Caregiver/Guardian aware of application? *
☐YES ☐NO
Would Parent/Caregiver/Guardian like assistance to complete CDU Forms?
☐YES ☐NO
Does the child identify as Aboriginal/Torrens Strait Islander *
☐YES ☐NO
Is this child under Guardianship of the Minister* If YES please provide Families SA Caseworker *
☐YES ☐NO
Is there a Family Court Order in Place? * Is Yes, please attach if copy
☐YES ☐NO
Is Interpreter Required? If yes, which language? *
☐YES ☐NO
☐UNSURE
Is the child registered with NDIS? *
Language:
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WCH CDU REFERRAL FORM
CHILD CARE CENTRE / PRE-SCHOOL / KINDERGARTEN / SCHOOL
CARE/EDUCATION APPLICATION REQUIREMENT Care/Education via Leadership Team in consultation Support Services eg.
Speech Pathology, Psychology or DECD Disability Coordinator/Catholic Education Special Education representatives .
CONTACT
ASSESSMENT
DATE
NAME(S)
LEADERSHIP TEAM
☐YES ☐NO
☐YES ☐NO
SPEECH PATHOLOGY
☐YES ☐NO
☐YES ☐NO
PSYCHOLOGY
☐YES ☐NO
☐YES ☐NO
DISABILITY COORDINATOR
☐YES ☐NO
☐YES ☐NO
BRIEFLY DESCRIBE PRESENTING PROBLEMS/AREAS OF CONCERN *
(including medical, developmental and educational concerns, if applicable)
MAIN REASON FOR COMPLETING CDU REFERRAL *
DETAILS OF PREVIOUS ASSESSMENTS *
(eg Psychology/Guidance, Speech Pathology, Physiotherapy, Occupational Therapy) - please attach copies of these reports
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WCH CDU REFERRAL FORM
PLEASE DESCRIBE ANY DIFFICULTIES THE CHILD IS HAVING IN THE FOLLOWING AREAS *
LANGUAGE UNDERSTANDING OR USE:
FINE MOTOR SKILLS, INCLUDING HANDWRITING:
GROSS MOTOR SKILLS (EG. BALANCE, COORDINATION):
SENSORY PROCESSING/RESPONSES:
SELF-HELP SKILLS:
SOCIAL SKILLS:
M AKING OR KEEPING FRIENDS:
BEHAVIOUR:
USING OR UNDERSTANDING GESTURES OR BODY LANGUAGE:
INTENSE OR UNUSUAL INTERESTS:
COPING WITH CHANGES
LEARNING NEW SKILLS/CONCEPTS:
SCHOOL PROGRESS:
ATTENTION AND CONCENTRATION:
Page 4 of 5
WCH CDU REFERRAL FORM
GENERAL HEALTH:
SLEEP:
DIET:
OTHER INFORMATION YOU WISH TO ADD
Update October 2015 AB
H:\CDU\CDU\proformas & templates\CDU Referral Form-written.doc
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