Building Tots Program - Intake Form

Building Tots is a program designed to help young children with or without a diagnosis to transition to an early childhood setting (preschool or long day care). You do not need NDIS to be eligible for this program & there is no cost to families. This program is fully funded by "Start Strong".

As part of the program we can:

Help you approach local centres that will suit your child's needs
Help you understand how your child will benefit from an early childhood setting
Keep in touch with you whilst you're on the waitlist for your preferred service
Provide practical support to your child's centre to help them support your child and understand their needs

Is your child attending childcare, Preschool or Family Day Care? *

YesNoWe're on waiting lists

Children are not eligible for this program if they're already attending an early childhood setting. If you're wanting to enquire about therapy services with Aspect, please complete the following form instead:

https://aspectics.snapforms.com.au/form/aspect-therapy---intake-form

CHILD'S INFORMATION

First Name *

Last Name *

Date of Birth *

Gender *

MaleFemaleOther

If other, please specify *

Street Address *

Street Address line 2 *

City *

State *

Post Code *

Country of Birth *

Home Language/s *

Aboriginal or Torres Strait Islander? *

YesNo

Interpreter Required *

YesNo

Please specify *

ADDITIONAL INFORMATION

Medications *

YesNo

Please provide details on medications *

Special Diet *

YesNo

Please provide dietary requirements *

Allergies *

YesNo

Please provide details on Allergies *

Health Care Card - Child *

YesNo

Health Care Card - Carer *

YesNo

Any other medical information/history?

Siblings (Name & DOB)

ENQUIRER/ REFERRER'S INFORMATION

First Name *

Last Name *

Email Address *

Mobile Phone *

Relationship to child *

Enquirer's Address *

Street address *

City *

State *

Postcode *

Is the person making the enquiry the child's Primary Carer? *

YesNo

CARER INFORMATION

First Name *

Last Name *

Email Address *

Mobile *

Relationship to child *

Country of Birth *

Is there an additional Carer? *

YesNo

ADDITIONAL CARER INFORMATION

First Name *

Last Name *

Email Address *

Mobile Phone *

Relationship to child *

Country of Birth *

SERVICES THE CHILD IS ACCESSING (IF APPLICABLE)

Type of Service (e.g. speech pathology)

Organisation providing the Service

OVERVIEW OF CHILD'S DEVELOPMENT

Strengths *

Areas Requiring Further Development *

Strategies in Place to Support Development *

Please note: The Building Tots Early Childhood Development Program is funded by the Department of Education under the Start Strong Initiative.

Please sign below to submit a referral for the Building Tots program. Our team will review the information and be in touch with further information on the program

Primary Carer (parent/guardian)

First Name *

Last Name *

Please tick if you are the referrer and are signing with permission from the family.

Signature *

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