IPC Health Autism Assessment Clinic Referral Form

Important Note

This clinic DOES NOT offer cognitive assessments.
We DO NOT offer single sign off diagnoses by a paediatrician where supporting assessments have been collected elsewhere.
If we don't receive the requested information, the referral won't be accepted. We will contact you for any needed additional referral information.
We complete assessments and feedback in a single day with the paediatrician and assessment team. Where possible, all parents/guardians need to be present on that day, as separate feedback sessions cannot be accommodated.
Our clinic specialises in providing multidisciplinary assessments for children. This means our assessments involve input from multiple professionals, including a paediatrician, psychologist, speech pathologist, and occupational therapist, to gain a comprehensive understanding of the child's needs. We do not provide assessments for children who may require a diagnosis of autism by a single clinician. Families seeking standalone diagnostic assessments for autism should be referred to a suitable specialist clinic or practitioner.
There is an out-of-pocket fee associated with this service.

Eligibility

Eligibility for IPC Health's Autism Clinic is as follows:

Please select ALL checkboxes to confirm your understanding of these eligibility criteria before you make this referral.

You are a paediatrician, paediatric fellow, or paediatric registrar referring to this clinic.

Child must be aged between 3 years 6 months and 11 years at the time of referral.

Child lives within Hobson's Bay or Wyndham catchment areas.

If the child is under 6 years of age, they MUST have been referred to the early childhood approach (ECA).

The child has Medicare and, Medicare 135 has NOT been billed previously.

Child has NOT had any previous autism assessments in the last 3 years.

Child is NOT appropriate for a single clinician diagnosis (as per national guideline Autism CRC 2023).

There is diagnostic uncertainty, and a differential diagnosis needs to be considered by a multidisciplinary team.

The child is engaged with an ongoing Paediatrician for management following an assessment and a future appointment has been booked.

The child has had hearing and vision tested prior to referral.

The Family / Legal Guardian has consented to this referral.

Referrer Details

Name of Referrer *

Referrers Provider Number *

Referrer's Profession *

Referrer's Phone *

Referrer's Email Address *

Practice / Organisation *

Child Details

Child's Name *

Date of Birth *

Gender *

Pronouns *

He/HimShe/HerThey/ThemOther

Child Identifies as: *

AboriginalTorres Strait Islander OriginAboriginal and Torres Strait IslanderNeither

Languages Understood and Spoken by Child

Interpreter Required for Child *

YesNo

Country Of Birth

Who does the child live with? *

Both parentsSingle parent

Living environment *

HomeKinship CareOut Of Home Care

If the child lives across multiple caregiver's houses, please specify how many days per fortnight they live at each residence

Caregiver 1 (number of days per fortnight)

Caregiver 2 (number of days per fortnight)

Is there Child Protection or Child First / Victorian Aboriginal Child Care Agency involvement? *

NoPreviouslyYes

If yes, please provide the following details:

Case Manager Name

Agency

Contact Phone / Email

Court Orders *

Yes- please attachNo

Are there any Custody Arrangements? *

YesNo

Please add details:

Potential barriers to the family attending appointments or accessing support?

Childcare/Kindergarten/School (if applicable):

Main Educators Name

Grade

Caregiver/Parent Details

Caregiver/Parent 1

Name *

Relationship to Child *

Address *

Phone *

Email

Primary Language Spoken *

Interpreter Required? *

YesNo

Caregiver/Parent 2

Name

Relationship to Child

Address

Phone

Email

Primary Language Spoken

Interpreter Required

YesNo

Other Professionals Involved In Child's Care

Please complete the following details if known.

Please include names, workplace location, and contact details.

Child is currently accessing NDIS funding: *

YesNoNot Sure

GP Details

Preschool Field Officer

Speech Pathologist

Occupational Therapist

Psychologist

Other

Consent and Declaration

Health Professional Declaration:

I have engaged in a conversation with the parents or guardian of the abovementioned child regarding the purpose of this referral, which is for an Autism Assessment. During our discussion, I conveyed that because of this evaluation, their child may receive a diagnosis of autism. The family/carer has expressed their understanding of this possibility and their willingness to proceed with the process of exploring an autism diagnosis for their child.

Health Professional Signature of Declaration: *

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Date of Signature: *

Referral Consent:

The referring professional has discussed with me/us their concerns and the reason for this referral.

The referring professional has completed this form in consultation with me/us.

I /We consent to this referral, and the information above being sent to and held by IPC Health.

The referring professional has emphasised/explained to me that:

a multidisciplinary assessment may not be conducted if the evaluation team determines that it is not required to establish an autism diagnosis for your child,
the multidisciplinary team will determine what assessments are required /deemed necessary when your child is referred to our clinic.

Caregiver/Parent Signature Acknowledging Consent

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Verbal Consent from Caregiver/Parent was provided *

Date of Consent Receipt: *

Please Confirm

Client requires a language assessment via the autism clinic *

YesNoNot Sure

You have referred child to the Early Childhood Approach (ECA)/NDIS *

YesN/A

If no, please see: Referral form | NDIS (bsl.org.au) (ECA) What is an Access Request Form? | NDIS (NDIS)

Additional Information

Please provide any additional information that would be helpful for our team to know

Attachments

Referral Letter *

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A comprehensive Paediatrician/Paediatric Fellow report/letter describing why client may meet criteria for ASD and requires a multidisciplinary assessment. Please address this letter to: IPC Health Autism Clinic 510 Ballan Road Wyndham Vale VIC 3024

Audiology Assessment Report

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If the child is 5 years old or younger, an audiology assessment needs to have been completed within the past 2 years, if > 5 years of age an audiology assessment must have been completed within the last 4 years.

OR

Referred for audiology assessment

Audiology assessment conducted, results pending

Allied Health Reports

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From a speech therapist, psychologist, and/or occupational therapist (e.g., key worker assessment, developmental assessment, language assessment, cognitive assessment)

Has child completed a vision assessment? *

YesNoUnsure

Vision Assessment Report

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From a speech therapist, psychologist, and/or occupational therapist (e.g., key worker assessment, developmental assessment, language assessment, cognitive assessment)

Court Orders (if applicable)

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Thank you for submitting this referral.

Should you have any questions or queries, please do not hesitate to contact our team:

autism@ipchealth.com.au