Casework Support Services

Please complete the below form in order to submit a referral for service delivery and we will ensure we respond within 24 hours. If the referral is urgent in nature (under 24 hours), please call 1300 912 956.

Child/Young Person's Details

Name

Date Of Birth

Address

Sex

Phone

Cultural Background

Unique Client Identifier (ICMS, Child Story Number, etc) – If Applicable

Complexity

Car Seat Required?

Guardian/Carer Details

Name

Address

Phone

Relation to Child/YP?

Referring Person/Organisation

Name

Phone

Organisation

Branch/Region

Email to send invoices

Please add any other emails for the people to whom this quote should be sent

Requirements

Reason for requesting service

Proposed frequency of service – Time, Date & Length

Service specific details – locations, people involved, pick up time, drop off time

Goals/Focus Areas

Detail the Child/Young Person’s history. Does the child/young person have a Client Information Form or About Me document? If so, please attach

Attach File

Upload supported file (Max 15MB)

If supervised contact, what level of interaction is required?

Level 1

Level 2

Level 3

Level 1: Contact worker to be heavily involved

Be within a few metres of the family at all times.
Attend bathroom with parent and child at all times.
Listen to all conversations at all times.
No alone time between child and parent.
Be directive and provide advice to parents as needed.

Level 2: Contact worker to be mostly involved

Parent allowed to take child to bathroom alone, remain in vicinity of bathroom (E.g. waiting outside)
Relatively close proximity at all times (5-10 metres)
Listening to most conversations.
Provide some feedback when appropriate/sought by the parent.

Level 3: Contact worker to be mostly observational

Not involved in bathroom visits.
Allow space for families.
Minimal interaction with parents and children during visits.

Does the Child/Young Person have any dietary requirements?

What are the Child/Young Person’s interests / hobbies?

Are there any medical issues / concerns? If yes, what are they? Is there any medication being taken by the Child/Young Person?

Are there any behavioural issues / concerns? If yes, what are they? - Is there a Behaviour Support Plan? Is there a Safety Plan? If so, please attach.

Attach File

Upload supported file (Max 15MB)

Any other relevant information

Casework Support Services

Child/Young Person's Details

Guardian/Carer Details

Referring Person/Organisation

Requirements

Thanks for submitting!