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Therapeutic Residential Supports

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?

Briefly outline the reason for the referral (placement breakdown, recent entry to care, shared care arrangement, placement preservation, etc)

Attach File

Upload supported file (Max 15MB)

Does the child/young person have a Client Information Form or About Me document? If so, please attach.

Yes

Please add any other relevant information

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

Type of Support Required

Intensive Therapeutic Care (24/7 short-medium term care)

Planned Therapeutic Respite

Safe Kinnections (keeping families safe)

Period Support is Required

Yes

Support Period Start Date

Support Period End Date

Is Accommodation Required?

Yes

What Region is the Accomodation Required?

Address Where Support is Needed

What Staffing Model is Needed

1:1

2:1

Other

Is an Awake Shift Needed?

Yes

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)

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)

Thanks for submitting!

The organisation acknowledges that these lands always were, and always will be, Aboriginal and Torres Strait Islander lands. We pay respect to the traditional custodians and the Elders within the Aboriginal and Torres Strait Islander communities in which we live and work.

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