Referral Form - familyandchild connect

I am a member of the public

I am a professional working for a prescribed entity under Child Protection Act 1999

I am a professional working in a government or non-government agency that is not a prescribed entity under Child Protection Act 1999

Original Referral Source *

Professional Non-Prescribed *

Regional Intake Service *

Child Safety Service Centre *

Child Safety Current Intervention Type *

Name of the entity

All of the following conditions must be met to make a referral to a service

The referred family has a child unborn to 18 years of age.
The child/ren listed in the referral are not currently subject to intervention with Child Safety.
Without support the child, young person and family are at risk of entering or re-entering the statutory child protection system.
The family would benefit from access to intensive and specialist support services.
The family has multiple and/or complex needs.

The referral meets the criteria above

If the referral criteria are not met

You may still respond in a number of ways depending on your knowledge of and relationships with family members.

Talk to the family about your concerns and discuss alternative support options including referrals to other appropriate support services.

Aboriginal and Torres Strait Islander Family Wellbeing Services can provide culturally responsive support to families, more information about these services and their locations is available on the Department’s website Aboriginal and Torres Strait Islander Family Wellbeing Services.

If you need assistance locating an appropriate support service, you may also consult with Family and Child Connect by calling 13FAMILY or visiting the website www.familychildconnect.org.au

You do not need to complete a referral to Family and Child Connect or provide any identifying information to Family and Child Connect. Simply call to explain the type of secondary service you are seeking and any special considerations (i.e. cultural, transportation, language).

You may also provide information regarding services and resources directly to the family.

Who am I? *

I would like to access a family support service to support me and my family.

I am completing this referral on behalf of the family who would like to access a family support service.

Name of parent/s who provided consent for this referral *

Primary
Alternative

Contact Name *

Telephone *

Email *

Contact Name

Telephone

Please provide details of family members below (at least one child and one adult are required)

Based on the location of this family your referral will be sent to:

Please select (highlight) the required service:

If you would like a copy of this referral sent to another person then please provide an e-mail address

To submit your referral, click the check box below to proceed

Who am I?

All of the following conditions must be met to make a referral to a service

If the referral criteria are not met

Referral

Referrer Details

Who am I? *

Your (referrer) Details

Family Details

Family Support Needs

Cultural Support Needs

Risk/Safety Factors

Previous Referral

Finalisation

Confirmation