This form is used to refer infants and children (0-5 years) for a hearing test, including infants or children with a risk factor for late onset hearing loss.

Form

Community Audiology Referral Form (Updated December 2024)

• This form will need to be downloaded and completed electronically
• Some audiology providers have specific referral criteria and forms required for referrals to their centre. Please check with the audiology provider to determine their requirements

Paediatric Audiology Centre list

View a list of Paediatric Audiology Centres in Victoria (updated 04/10/2024)

Note: This list may not include all paediatric audiology providers in Victoria. Inclusion on this list does not include endorsement by VIHSP.

When should the infant/child be referred to an audiologist for a hearing test?

• If a parent, carer or health care provider have concerns about the infant's hearing, speech, language or communication development
• When an infant/child has a risk factor for hearing loss

If the infant or child is already under the care of an audiologist they do not need to be referred again.

How do I make a referral to a paediatric diagnostic audiology centre?

1. Identify the centre where you would like to refer the infant. Paediatric Audiology Centres in Victoria
2. Check the criteria below with the selected audiology centre as these can be different for each centre

• Ages of infants/children seen at the service
• Any fee applicable
• Who can make the referral - parent, GP, MCH nurse, other health professional
• Whether a specific referral form is required by that service
• What information is required on the referral (e.g. a named audiology provider)
• How the referral should be forwarded to the audiology service (e.g. online, hardcopy, fax, email etc)

3. Complete the appropriate referral form - specific audiology centre form or Community Audiology Referral Form
4. Record the referral/audiology appointment as per your organisational requirements.
    Note: VIHSP does not require a copy of the referral