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02 6626 3700
PO Box 580
Lismore NSW 2480
Balaa Family Supervision Form
Supervised Family Time Referrer Details
Referrer Name
Staff Member
Contact Number
Email Address
Child or Young Person’s Identifying Information
Name
Date of Birth
DD slash MM slash YYYY
Age
Gender
Nationality
Aboriginal
Torres Straight Islander
Non Indigenous
Other
If the child or young person is Aboriginal and/or Torres Strait Islander, what is the child or young person’s nation(s)/tribe(s)?
Child seat required
YES
NO
FORWARD FACING
REAR FACING
Parent Caregiver Details
Carer Name
Carer Phone
Carer Address
Case Plan Goals
No Court Orders
Long Term care Childrens Court
Restoration to parent/s
Guardianship Orders
Other Court Order/s
If Other, give details.
Risks and Agreement
Are there any known risks?
YES
NO
Has a risk assessment been completed? (attach copy)
YES
NO
Have all parties signed the family time agreement and read the guidelines?
YES
NO
Details of Referral
Commencement Date
DD slash MM slash YYYY
End Date
DD slash MM slash YYYY
Frequency of Sessions
Estimated Travel Time per Session
Estimated Number of Kilometres per session
CYP Pickup Address
CYP Dropoff Address
Venue 1 (Preferred) Address
Venue 2 (alternate eg- wet weather) Address
Attendees
Other Details (eg Food, Activity-Entry Fee)
Please Complete Details of Your Referral Here
Attachments
Drop files here or
Select files
Accepted file types: pdf, docx, doc, jpg, png, Max. file size: 128 MB.
Terms & Conditions
a. In the event that the referrer cancels, recalls or suspends a Request for Services Form after 2:00pm the day before, the referrer will pay the Service Provider a sum equivalent to 3 hours of the staff rate for the applicable Service Type. No fee in respect of transport costs will be payable. b. A minimum engagement period per event of 3 hours, including 1 hour report writing time applies for each mentoring referral. c. Any fees or cost associated with of lateness on the part of a client, carers or parents, or other Service Provider, will be payable by the referring service. d. Lateness on the part of participants will result in cancellation of the family time event if more than 15 minutes after commencement time for the event, unless otherwise notified or negotiated. e. A copy of the Ngunya Jarjum family time agreement must be signed by all participants prior to engagement of services, this agreement forms the terms of family time services. f. Report will be available to the referrer within 48 hours of the event where requested. g. All accounts are payable within 14 days of invoicing, multiple events will be invoiced monthly.
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