Balaa Supervised Transport Referral Transport 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 Restraint Required? YES NO Front Facing Rear Facing 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 detailsAre there any known risks? YES NO Has a risk assessment been completed? (Attach copy) YES NO Details of ReferralProposed Start Date DD slash MM slash YYYY Frequency of Sessions Person Responsible CYP Pickup AddressCYP Dropoff AddressEstimated Travel Time per Session Total estimate travel per event from 70 Carrington Street, Lismore to pick up point and drop off point to office for return tripEstimated Number of Kilometres per session Total estimate travel in kilometres per event from 70 Carrington Street, Lismore and returnWill Return transport be required? YES NO If YES day and time of pick-up for return Detailse.g. – carer will pack food for child, entry fee to venue to be paid for by Balaa and will be reimbursed through invoicing after service deliveryOther 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.
