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Details of parent or carer you are referring
Kiind supports families of children living with disability, developmental delay, autism, genetic, rare, undiagnosed and/or chronic conditions. We provide practical assistance, emotional support, connection to other families and help to find the most appropriate services and supports for children and their families. All services are provided
free-of-charge
.
Name
*
Surname
*
Preferred pronouns
*
She/her/hers
He/him/his
They/them/theirs
Mobile
Email
*
Preferred method of contact
Phone
Email
Is this person of Aboriginal or Torres Strait Islander origin?
Yes
No
Is this person from a culturally and linguistically diverse background?
Yes
No
What is this person's preferred language/s?
*
Does this person require an interpreter?
*
Yes
No
Address
Suburb
Postcode
Details of child with disability and/or additional needs
Name
*
Date of birth
*
Day
Month
Year
Gender
*
Male
Female
Non-binary / Gender diverse
Prefer not to say
Other
Other
*
Relationship of person being referred to child:
*
Father
Mother
Foster parent
Step-parent
Grandparent
Family carer
Guardian
Other
Other
*
Primary diagnosis / condition
*
Reason for referral:
*
Details about you, the person referring this family
Name:
*
Surname:
*
Position:
*
Department (if applicable):
Organisation:
*
Telephone
*
Email
*
Please indicate if you would like further information about Kiind and how we support families to navigate the world of disability.
Please indicate if you would like further information about Kiind and how we support families to navigate the world of disability.
Consent
Please confirm:
*
You have received consent from the person that you are referring to contact Kiind on their behalf.
You have received consent from the person that you are referring that Kiind may contact them for support.
By submitting this form, you consent to Kiind's collection and use of personal data in accordance with our privacy statement. To learn more about our data collection and usage practices, please visit our
Privacy Policy
