CU@HOME REFERRAL
The Child & Health Parenting Service (CHaPS)
STATEWIDE	
PT ID	

	

	

	

    Family Name:  <PtSurname>   D.O.B. <PtDoB>
Other Names:   <PtFirstName> <PtMidName>	

 Address:   	

<PtAddress>	

FACILITY/SERVICE:  <Region>	

  Date:      <TodaysDate>   
  Referrer:  <DrName> 
  Agency: <Practice>   <DrStreet>  <DrCity>   <DrPostcode> 
  Phone number:  <DrPhone>           Fax Number: <DrFax>  
  Email Address:  <DrEmail>	

  Has the client consented for cu@home involvement ?		<Has client consented to CU@home involvement>
  (If the answer is No the referral cannot be accepted)	

Client Details:	

  Name:  <PtName>        Age: <PtAge> 
  Phone:  <PtPhoneH>   Mobile: <PtPhoneMob>
  Permission to Contact:  By Mail:  <Permission to contact client by Mail?>              By Phone: <Permission to contact client by Phone?>	

   Additional Contact:  <Additional Contact Person>        Ph Number: <Other Contact Phone Number>	

 Father of baby:	

  Name:  <Father of Baby name>
  Date of Birth: <Father Date of Birth>       Age: <Father Age>	

Intake Criteria:	

 
	
 First Baby	
	
 Age 15-19	
 Expected date of Delivery <Expected Delivery Date>	

 Issues/Challenges: (for example pregnancy history, social support network, education/employment, financial, housing, substance use, relationship with partner)  <Note>	

 

	

   Any queries, call 1300 064 544 The Child Health and Parenting Service (CHaPS) STATEWIDE.	

Please send the referral to cu@home in your region:	

cu@home  NORTH	
cu@home  SOUTH	
cu@home  NORTH WEST	

chapsadminnorth@ths.tas.gov.au	
cuhomeschaps@ths.tas.gov.au	
chaps.parentingcentrenw@ths.tas.gov.au