Balaa Family Supervision Form Supervised Family Time Referrer DetailsReferrer Name Staff Member Contact Number Email Address Child or Young Person’s Identifying InformationName 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 DetailsCarer 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 AgreementAre 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 ReferralCommencement 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 AddressCYP Dropoff AddressVenue 1 (Preferred) AddressVenue 2 (alternate eg- wet weather) AddressAttendeesOther Details (eg Food, Activity-Entry Fee)Please Complete Details of Your Referral HereAttachments 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.
