Balaa Professional Services Professional Services Referrer DetailsReferrer Name Agency Contact Number Email Address AddressType of Service Aboriginal Consultancy Reconcilliation Action Plan Cultural Case Planning Complex Case Support Other 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)? Parent Caregiver DetailsCarer Name Carer Phone Carer Address Legal StatusLegal Status No Court Orders Restoration Children’s Court (NSW) Guardianship Children’s Court (NSW) Interim Children’s Court (NSW) Long term care Children’s Court (NSW Family Law Court (Aust) Other If Other, give detailsDetails of ReferralProposed Start Date DD slash MM slash YYYY End Date DD slash MM slash YYYY Frequency of Sessions Session Length Provide Overview of ReferralPurpose/Desired Outcome/GoalsProposed Timeframe e.g. - 6 monthsFrequency e.g. - one off, fortnightly etcReporting requirements e.g. - monthlySupporting Documnets Provided e.g. - Genogram, case plan etcOther information relevant to support service delivery?Attachments (if any)Max. file size: 128 MB.Attachments (if any)Max. file size: 128 MB.TERMS and 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 mentoring 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. Report will be available to the referrer within 48 hours of the event where requested. e. All accounts are payable within 14 days of invoicing, multiple events will be invoiced monthly.