Referral Details

Referral Date

Where are you referring from? *Select self-refer if you are making an enquiry for yourself

Referral Source Other

Eligibility Details

How can we help?

Information about abortion and/or abortion providers

Support to make a decision about a pregnancy

Support to access an abortion

Information about adoption/kinship

Information about parenting

Post abortion support

Under-16 pregnancy options and support

General CbyC Service Information

Termination of Pregnancy (ToP) funding

Other - please specify

How can we help (other)

Are you the pregnant person?

YesNoNot applicable

What is your relationship with the pregnant person?

Relationship with pregnant person (other)

Are you/the pregnant person living in Queensland?

YesNoNot applicable

Residency Status

Temporary Visa - Other

Referral Contact Details

This section only needs to be completed for referrals from organisations, services, or formal supports.

Referral Agency

Referrer Full Name

Referrer Occupation

Referrer Occupation Other

Referrer Phone/Mobile Number

Referral Email Address *

What is your preferred contact method?

Have you engaged with us before?

How did you learn about Children by Choice?

How did you learn about us Other

Pregnant Person Details

Given Names *

Family Name *

Preferred Name

Pronouns

Date of Birth *

Gender *

Country of Birth

Do you identify as a First Nations community member?

Do you identify as a member of the LGBTQI+ community?

YesNoPrefer not to say

Will you require an interpreter?

YesNoNot applicable

If yes, which language?

Phone Number

Mobile Number *

Do you have any children?

YesNoNot applicable

If yes, how many children?

If we need to leave a message, is it safe to say we are calling from Children by Choice?

YesNoNot applicable

Residential Address

Is your housing stable?

YesNoN/APrefer not to say

Address Line 1

Address Line 2

Suburb/City

State

Postcode

HHS Catchment Area (if known)

Pregnancy Details

How many weeks is the pregnancy today?

Pregnancy Weeks

Pregnancy Days

How was the pregnancy confirmed?

When did you confirm your pregnancy?

How was the pregnancy confirmed?

Ultrasound

Blood test

Home pregnancy test / urine test

GP urine test

Missed period

Counted from the first day of last normal menstrual period

Not yet confirmed

If known, when is the first day of the client's last normal mentrual period?

Abortion Details

Only fill out this section if you are seeking post-abortion counselling and support.

When did you get the abortion?

What type of abortion did you experience?

Abortion method (other)

If known, at what gestation (in weeks) did you get the abortion?

Gestation Weeks

Gestation Days

Additional Information

Any other relevant information? (e.g. financial stress, domestic and/or family violence, safety concerns)

Client Consent

To allow us to share your information with other services (like a hospital or social services), please complete the Client Consent section.

I/the client gave consent to share information with external organisation/s

Consent End Date (do not give my/the client information after this date)

Organisation/s allowed to receive my information

Information to be EXCLUDED when sharing with other organisation/s