BOOK A DOCTOR
  • Our services
    Medical Services
    • Doctors
    • Paediatric (Children’s) Clinic
    • Refugee Health Clinic
    • Lymphoedema
    • Pathology
    • Pharmacotherapy
    • Medicare Urgent Care Clinic Northcote
    • Seniors Lifestyle Victoria
    Dental Services
    • Public Dental
    • Low Cost Private Dental
    • $153 new client offer
    • Children’s Dental
    Mental Health Services
    • Counselling
    • Private Psychology
    Physical Health Services
    • Physiotherapy
    • Dietetics
    • Exercise Groups and Classes
    • Diabetes Education
    • Podiatry
    • Speech Pathology
    • Occupational Therapy
    • Optometry
    • NDIS
    • Aged Care
    • Community Health Nurse
    • Early Childhood Approach
    Support Services
    • Trans and Gender Diverse Community Health Program
    • Aboriginal and Torres Strait Islander Health
    • Youth Support
    • Stop Smoking Support
    • Darebin Men’s Shed
    • Needle and Syringe Program
    • Social Support
    • Community Programs
    • Health Coach
    • LGBTIQA+ Health
  • Client information
    • New client welcome pack
    • Your feedback
    • Our fees
    • Being respectful to our staff and clients
    • Your rights and responsibilities
    • Privacy and confidentiality
    • Quality and Accreditation
    • Child Safe practices
  • News and events
    • News
    • Events
  • Get involved
    • Careers with us
    • Volunteer with us
    • Community Advisory Committee
    • Become a Member
    • Student placements
    • Donate now
  • About us
    • About us
    • Our locations
    • Our Climate Our Health plan
    • Being Valued Toolkit
    • Kaydo Kertheba plan
  • Donate
  • Make a Referral
  • Our Locations
  • Contact Us
Skip to main content ( press enter )
Translator
  • Donate
  • Make a Referral
  • Our Locations
  • Contact Us
(03) 8470 1111
CALL
Header Logo
  • Our services
    Medical Services
    • Doctors
    • Paediatric (Children’s) Clinic
    • Refugee Health Clinic
    • Lymphoedema
    • Pathology
    • Pharmacotherapy
    • Medicare Urgent Care Clinic Northcote
    • Seniors Lifestyle Victoria
    Dental Services
    • Public Dental
    • Low Cost Private Dental
    • $153 new client offer
    • Children’s Dental
    Mental Health Services
    • Counselling
    • Private Psychology
    Physical Health Services
    • Physiotherapy
    • Dietetics
    • Exercise Groups and Classes
    • Diabetes Education
    • Podiatry
    • Speech Pathology
    • Occupational Therapy
    • Optometry
    • NDIS
    • Aged Care
    • Community Health Nurse
    • Early Childhood Approach
    Support Services
    • Trans and Gender Diverse Community Health Program
    • Aboriginal and Torres Strait Islander Health
    • Youth Support
    • Stop Smoking Support
    • Darebin Men’s Shed
    • Needle and Syringe Program
    • Social Support
    • Community Programs
    • Health Coach
    • LGBTIQA+ Health
  • Client information
    • New client welcome pack
    • Your feedback
    • Our fees
    • Being respectful to our staff and clients
    • Your rights and responsibilities
    • Privacy and confidentiality
    • Quality and Accreditation
    • Child Safe practices
  • News and events
    • News
    • Events
  • Get involved
    • Careers with us
    • Volunteer with us
    • Community Advisory Committee
    • Become a Member
    • Student placements
    • Donate now
  • About us
    • About us
    • Our locations
    • Our Climate Our Health plan
    • Being Valued Toolkit
    • Kaydo Kertheba plan
BOOK A DOCTOR

Make a Referral

Make a Referral

These online referral forms help us understand your needs, so that we can provide you with appropriate, high quality care.

Make a Referral

You may be asked to complete a form before attending your first appointment.

Please contact us on (03) 8470 1111 for all other referral forms.

Referral forms for children

These forms should be completed by a parent or carer.

  • Booking with our Paediatrician Clinic requires a GP referral, please see this page for more information.
  • For Allied Health appointments for children aged 0 – 6 years, who have not yet started school, and whodo not have NDIS funding, please complete this Referral Form: For Children aged 0 to 6 years. 
  • For SP and OT referrals for children aged 0 – 8 years with NDIS funding, please complete this SP and OT NDIS Referral Form
    • The first section of the referral form lists diagnoses such as autism, but we can also support children with other diagnoses. If your child does not have a diagnosis, or has a diagnosis that is not listed on the referral form, please continue to complete the form. We will contact you to discuss your referral.

Once your child has an appointment

These forms should be completed by a parent or carer.

  • Prior to your child’s Allied Health appointment, please complete the Getting to Know Your Child form.

Referral forms for young people and adults up to 64 years

  • Counselling: Referral form
  • NDIS: Referral form
  • Trans and gender diverse health: Service access form
  • Private Psychology: Intake form

Referral forms for adults 65 years and over

  • Counselling: Referral form
  • Support at Home: Referral form

Your CH Footer Logo
Get the latest news straight to your inbox
Please enable JavaScript in your browser to complete this form.
Loading
Services
  • Make a Booking
  • Make a Referral
  • Commercial Services
  • Languages
  • FAQs
Company
  • About
  • Locations
  • Careers
  • Donate Now
Connect
(03) 8470 1111
In an emergency, dial 000
info@yourch.org.au
Contact Us
Affiliations and Accreditations
Aflliation and Accrediatiotns
Aflliation and Accrediatiotns
Aflliation and Accrediatiotns
Memberships
Membership
Membership
Membership
Membership
Membership
Black Red yellow Flag
Blue Star Flag

Your Community Health acknowledges the Wurundjeri people of the Kulin Nation as the traditional custodians of the land. We pay our respects to Elders past, present and emerging, and acknowledge that sovereignty was never ceded.

Transgender Flag
Trans Flag
Flag

Your Community Health is committed to providing an inclusive and accessible environment where people and communities of all identities and backgrounds
(including but not limited to, ethnicity, faith, socio-economic circumstance, sexual orientation, gender identity, ability, bodies, migration status, age and Aboriginal and Torres Strait Islander descent) are accepted, safe and celebrated.

Privacy Policy
Copyright © Your Community Health. All rights reserved.
|
Privacy Policy
Website design by
Manage Consent
To provide the best experiences, we use technologies like cookies to store and/or access device information. Consenting to these technologies will allow us to process data such as browsing behaviour or unique IDs on this site. Not consenting or withdrawing consent, may adversely affect certain features and functions.
Functional Always active
The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.
Preferences
The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.
Statistics
The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.
Marketing
The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.
  • Manage options
  • Manage services
  • Manage {vendor_count} vendors
  • Read more about these purposes
View preferences
  • {title}
  • {title}
  • {title}