Caseworker Information
First Name
Last Name
Email
Mobile Number
Example: 04xxxxxxxx
Name of your organisation
Client Information
First Name
Last Name
Email
Mobile Number
Example: 04xxxxxxxx
Residential Town
Residential LGA
Please select...
Bass Coast Shire
City of Bendigo
City of Brimbank
City of Casey
City of Greater Dandenong
City of Hume
City of Latrobe
City of Melton
City of Monash
Other/Unknown
Shire of Baw Baw
Shire of Cardinia
Shire of East Gippsland
Shire of Wellington
South Gippsland Shire
Residential Postcode
Date of Birth (dd/mm/yy)
Referral Information
Primary Reason for Referral (select one - for further details read our referral policy)
Please select...
Psychosocial & Emotional Support
Improving Social Support & Community Engagement
Parenting & Community Education
Mental Health (EPDS Monitoring and Referral where Appropriate)
Other
Other Reasons
Is the client pregnant?
Please select...
Yes
No
Client's Expected Due Date
If the client is expected to birth sooner than their due date, please list the earlier anticipated date
Is your Client Expecting
Please select...
Single Baby
Multiple Babies
Does your client require birthing supports?
Please select...
Yes
No
Not sure
Where does your client plan to birth
Please select...
Dandenong Hospital
Leongatha Hospital
LRH (Traralgon)
Monash Clayton
St John of God
WGHG (Warragul Hospital)
Wonthaggi Hospital
Has the client recently given birth?
Please select...
Yes
No
At what gestation was the infant born
Baby's Gender
Please select...
Boy Baby
Girl Baby
Unknown
Baby's Name
Client/Family Circumstances (check any that apply)
Kinship/Foster Care
Low Income
Disability (either parent, sibling or infant)
Family Violence (either current or at risk)
Homelessness, or at risk of
Life Controlling Addiction
Migrant/Refugee/Asylum
Youth < 21
Mental Health (current or at risk of)
Medical/Health Reasons
Single Parent
Unemployment
Other
Health/Lifestyle (check any that apply)
Adequate nutrition
On folic acid/vitamins
Client has current or previous mental health issues
Current mental health issues
Previous pregnancy complications
Client is a current smoker
Client currently drinks alcohol
Client currently or has recently used illicit drugs
Past illicit drug use
If the Client's has a Partner, is he the Baby's Father?
Please select...
Yes
No
Does the Partner/Father of the Baby live with the Client?
Please select...
Yes
No
For the safety of our interactions with the client and/or partner/father of
the baby -have you identified any risk or presence of Domestic Violence/Family Violence
Please select...
Yes
No
Not Yet Assessed
Does the Partner/Father of the baby require support?
Please select...
Yes
No
To help us assess the client's safety and priority, please tell us whether the client has recently attempted suicide or expressed suicidal ideation
Please select...
Yes
No
Unknown
Please provide further information around mental health concerns if applicable/relevant
Primary language spoken at home
Is an interpreter required?
Please select...
Yes
No
Maybe
Does anyone in the family have a current Health Care Card?
Please select...
Yes
No
Does the Client identify as Aboriginal and/or Torres Straight Islander?
Please select...
Aboriginal but not Torres Strait Islander origin
Torres Strait Islander but not Aboriginal origin
Both Aboriginal and Torres Strait Islander origin
Neither Aboriginal or Torres Strait Islander origin
Not stated/inadequately described
Does anybody else in the immediate family (father, infant, other children)
identify as Aboriginal and/or Torres Straight Islander (check all that apply)?
Please select...
Yes
No
Prefer not to answer
Is this client being supported by another agency?
Please select...
Yes
No
Please provide details of any other services currently engaged in supporting this client (Organisation and Case Worker please) If none, state 'none'
How did you hear about us?
Yes client has consented for information to be shared and to be contacted by Olivia's Place
Please select...
Yes
No