2022 Practitioner/Agency Referral Form
Section A: Important information
This form is to be completed by a specialist practitioner or an agency working with the
student in order to determine a students eligibility for enrolment with Virtual School Victoria
(VSV) and to assist with the development and coordination of learning and support plans.
A Practitioner/Agency Referral Form completed by a General Practitioner (GP) will not
be accepted.
Full-time enrolment at VSV requires the student to be withdrawn from the environment of their
local school to undertake study through online learning platforms from their family home
under the supervision of a parent/carer. Students are expected to participate in online classes.
VSV does not receive funding through the Victorian or Commonwealth student disability
support funding programs (PSD, NCCD).
Enrolment is for the current academic year only. It is expected the student will return to a
local school after this time or will be required to reapply for enrolment at VSV.
VSV recognises that an important prerequisite for successful engagement with education is
the establishment of eective ongoing treatment and support for health conditions and
complex social circumstances. Referral information should demonstrate the student will be
receiving ongoing professional treatment and/or support for their condition/s and are
committed to using these supports.
Students enrolled at Virtual School Victoria require supervision by a parent or carer.
Supervisors are required to perform a range of duties including:
facilitating communication between the student and teachers
ensuring age appropriate adult supervision of the student
engaging with material provided by VSV both in a written and verbal format
ensuring that the student has access to a telephone, computer, reliable internet
connection and suitable work area
supporting the student to engage and participate in the learning program and the wider
school community
ensuring the student submits work in accordance with the prescribed or negotiated
submission timetable.
Online Classes
All Year 7 - 10 students participate in regular timetabled online classes. Online attendance is an expectation.
If this is not possible due to personal circumstances, students, parents/carers/supervisors must contact the
relevant Student Coordinator to arrange an exemption.
Practitioner/Agency recommendation for online class attendance:
Student is able to attend and participate in online classes.
Student is able to attend and observe online classes.
Student will require additional support to attend online classes.
Student is not currently able to attend online classes.
Patient/Client Details
Date of
Practitioner/Agency Details
Title: Name:
Other: (specify)
Psychology service
Private Psychologist
DFFH Child protection
Child & Adolescent Mental Health Service
Paediatric service
Community-based service
Navigator program
Hospital-based service NDIS
Provider Number:
(for Practitioners)
Private psychiatrist
Section B: Information to determine a students eligibility and support their enrolment
2022 Practitioner/Agency Referral Form
Practitioner/Agency Recommendation
100% EFT or 24 hours per week (full-time)
75% EFT or 18 hours per week (part-time)
50% EFT or 12 hours per week (half-time)
25% EFT or 6 hours per week (part-time)
0% EFT or 0 hours (not ready to learn)
The Victorian Curriculum requires that a full-time student in Foundation to Year 10 is engaged in 25 hours of
learning per week in a range of subjects from all of the Learning Areas. At Virtual School Victorian one hour is
allocated to SEL - Social & Emotional Learning (or Student Contact).
Practitioners are asked to provide detailed information related to a student’s workload capacity expressed
as Equivalent Full Time (EFT) or number of hours on the Practitioner Agency Referral Form (PARF) prior to
enrolment to inform learning program planning for the student.
2022 Practitioner/Agency Referral Form
Patient/Client Referral Information
How long has your patient/
client been under your care?
How much contact have you
had in this time?
Please indicate frequency (weekly,
fortnightly, monthly, etc)
What are the presenting issues
or conditions relevant to your
patient/client’s enrolment
at VSV?
Does this patient/client have
a diagnosed disability?
How do these conditions
inuence your patient/client’s
ability to attend mainstream
How will these conditions
aect the student’s ability
to engage in online learning
at VSV?
What treatments or
interventions will be put in
place to enable your patient/
client to engage with online
learning at VSV to the best of
their ability?
Which practitioner will provide
ongoing treatment and
monitoring during the students
enrolment with VSV?
Plan to return to mainstream school
What treatments or supports
do you believe are necessary
to assist your patient/client to
return to mainstream school?
What time frame do you believe
will be required to enable this?
By mid-2022 By the end of 2022 or beyond
Physical Visual impairment Intellectual disability Hearing impairment
Autism Spectrum Disorder Severe language disorder Severe behaviour disorder
Please provide details:
Anxiety Depression School refusal Bullying Behavioural issues
ASD ADD/ADHD ADD/ADHD Gaming issues Gender Dysphoria
Chronic fatigue Sleep disorder Eating disorder Trauma Pregnancy/parenting
Suicide risk
Other: (please specify)
If the student presents with suicide risk, please provide further information on the nature or
level of risk and provide a copy of the current safety plan.
2022 Practitioner/Agency Referral Form
Section C: Endorsement of the enrolment
I recommend withdrawal from mainstream schooling and a full enrolment with VSV.
I recommend a shared enrolment with VSV and an appropriate mainstream school.
I will provide ongoing treatment and monitoring for the duration of the enrolment.
I am prepared to be contacted to provide further information and for the purpose of supporting
my patient/clients progress.
I have obtained the consent of the parent/carer or independent student to provide this information
to the Department of Education and Training and VSV.
I believe the parent/carer is capable of meeting the supervisor requirements.
Signature: Date:
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
Once completed, this form can be returned to the patient/carer, or sent directly to VSV via post, fax, or email:
Virtual School Victoria
315 Clarendon Street,
Thornbury, VIC 3071
(03) 9416 8487
All information obtained in this form is dealt with in accordance with VSVs Privacy Policy and the
Department of Education and Training policies and procedures regarding privacy and record keeping.
Queries can be addressed to the VSV Enrolment Oce on (03) 8480 0000.
Name Role Contact Number/Email
Please list other professionals/agencies assisting your patient/client at the moment:
(if applicable)
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