Balaa Family Supervision Form

Supervised Family Time Referrer Details

Child or Young Person’s Identifying Information

DD slash MM slash YYYY
Child seat required

Parent Caregiver Details

Case Plan Goals

Risks and Agreement

Are there any known risks?
Has a risk assessment been completed? (attach copy)
Have all parties signed the family time agreement and read the guidelines?

Details of Referral

DD slash MM slash YYYY
DD slash MM slash YYYY
Drop files here or
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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