Balaa Family Led Decision Making Family Led Decision Making Referring DetailsReferrer Name Date of Referral DD slash MM slash YYYY Referring Agency Proposed FGC Location Direct Phone Number Mobile Phone Number Email Manager Contact Is there any planned leave in the next 4-8 weeks for the referrer?Preferred model for FLDM Family Yarnup Family Group Conference Has the Family Group Conference process been discussed with the family, including the reason for referral? Yes No Has the Family Group Conference process been discussed with the family, including the reason for referral?Mother's Consent Yes No Date DD slash MM slash YYYY FileAccepted file types: pdf, doc, docx, , png, jpg, Max. file size: 128 MB.Father's Consent Yes No Date DD slash MM slash YYYY FileAccepted file types: pdf, doc, docx, , png, jpg, Max. file size: 128 MB.Guardian's Consent Yes No Date DD slash MM slash YYYY FileAccepted file types: pdf, doc, docx, , png, jpg, Max. file size: 128 MB.Young Person's Consent (over 10 yo) Yes No Date DD slash MM slash YYYY FileAccepted file types: pdf, doc, docx, , png, jpg, Max. file size: 128 MB.Other Person's Consent Yes No Date DD slash MM slash YYYY Name/s Are any others consent required? Yes No Other Person's Consent Yes No Date DD slash MM slash YYYY Name/s Reason for No ConsentOther StaffFamily RelationshipsChild Young Person 1 Date of Birth DD slash MM slash YYYY Service Request Number Child Young Person 2 Date of Birth DD slash MM slash YYYY Service Request Number Child Young Person 3 Date of Birth DD slash MM slash YYYY Service Request Number Child Young Person 4 Date of Birth DD slash MM slash YYYY Service Request Number Child Young Person 5 Date of Birth DD slash MM slash YYYY Service Request Number Child Young Person Contact DetailsMother's Name Phone Address Father's Name Phone Address Legal Guardian's Name Phone Address Extended Family or Other Significant People Invted to Attend the FGCName Address Phone Relationship to Child Name Address Phone Relationship to Child Name Address Phone Relationship to Child All participants listed must be spoken to by the referrer regarding the FGC prior to FGC facilitator contactBackground InformationAre there any known risk, safety and wellbeing issues that need to be addressed within the family group conference?What are the non-negotiables for the family attending the family group conference?Is there anyone who cannot attend the conference because of an AVO or other legal restriction?Is there another influential person in the immediate or extended family that is considered a risk to the child/young person or any other family members likely to be attending the family group conference?Other Agencies or service involvedAgency Name Contact Person Contact Details Role with Family Agency Name Contact Person Contact Details Role with Family Agency Name Contact Person Contact Details Role with Family Agency Name Contact Person Contact Details Role with Family Whats Next? If additional information is required to provide the service, our Balaa Coordinator will make contact with you. Our team will provide you with a written quote for service, on accepting the quote you would provide a purchase order number. Once we receive the purchase order we can proceed to allocate the Family Group Conference, with a target completion 6-8 weeks. Withdrawal by family or referrer will incur a pro-rata fee for services delivered, including writing of closure report. All accounts are payable within 14 days of issue. Any further information or enquiries, contact Matthew Kenny, Manager Balaa and Gumaguy on 02 6626 3700 or email your enquiry to balaa@ngunyajarjum.com Documents to be attached to the referral: • Genogram • Any former agreements made by the family • Child case plan if in OOHC • Childs Cultural plan if applicable • Copies of any AVOs applicable to the referral • Signed consent forms for family members participating Files For Upload Drop files here or Select files Accepted file types: pdf, doc, docx, png, jpg, Max. file size: 128 MB, Max. files: 10. PhoneThis field is for validation purposes and should be left unchanged.
