Children's Contact Service - Application Form

An application form is to be filled out by each parent* (*The term 'parent' is interchangeable with any significant person in the child's life requiring this service.)

Application forms need to be received from both parents before we can progress.

LIST NAMES OF BOTH PARENTS AND CHILDREN

Name *

Relationship *

DOB *

Language *

Gender *

Suburb *

Country of Birth *

SERVICE TYPE REQUESTED

Please select the Service Type Requested *

Supervised VisitFacilitated Changeover

Do the children live with you?

Yes No

Address *

Street address: *

Suburb: *

State: *

Postcode: *

Preferred Contact Number: *

Do you have a secure email where we could send confirmation letters and schedules?

YesNo

If yes, please provide email address

Do any of the following apply to you?

Substance abuse issue? (alcohol/drugs)Illness / disabilityDo you possess firearms?Criminal charges / convictions? (Please provide any paperwork)Have you been / being harassed?Have you been stalked?Has there been any assaults (verbal or physical) of family members / others?Has an Intervention Order been in place? (If yes, provide a copy of the current Order)Have there been breaches of these Orders?

If you answered yes to any of the above, please provide details.

Are there Family Court Orders? (If yes, please provide a copy with this application) *

YesNo

Please Attach a Copy of Court Orders / Agreement Documents

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Is child protection currently involved with your family? *

YesNo

Briefly outline why you have applied to use this Service?

What year did you separate?

Briefly describe the reasons for separation?

When and under what circumstances did the children last see the parent they do not live with?

How do you think the child/ren feel about spending time with the parent they do not live with?

Are there any behavioural or health concerns about the children that we need to be aware of? (please provide details)

Have you used a children's contact service in the past?

YesNo

If yes, please briefly outline service used and when (eg. Child Contact Service, Parenting Orders Program or Family Relationship Services)

Are there any other services involved with you or your family eg (counsellor, support worker, psychologist) ?

The service is open for changeovers and supervised visits Thursdays-Sundays. Please select the days and time slots that you would be available (more than one can be selected)

ThursdayFridaySaturdaySunday

LEGAL REPRESENTATION

Do you have legal representation? ( If yes, please provide detail below)

YesNo

Solicitor's Name:

Organisation:

Solicitor Address:

Street address:

City

State

Postcode

Solicitor's Phone Number:

Solicitor's Email Address:

Has an Independent Children's Lawyer been appointed?

YesNo

Solicitor's Name:

Organisation:

Solictor's Address:

Street address:

City:

State:

Postcode:

Solicitor Phone Number:

Solicitor's Email Address:

OTHER PARENT'S DETAILS

Parent's Name: *

Relationship to child/ren: *

Do any of the following apply to them?

Substance abuse issue? (alcohol/drugs)Illness/disabilityDo you possess firearms?Has an Intervention Order been in place? If yes, provide a copy of the current intervention order.Have there been breaches of these Orders?Criminal charges/convictions?

If you answered yes to any of the above, please provide details.

Is there any other issue/detail about your situation that we should be aware of in relation to you and your child/ren attending this service?

Please provide comments if required.

The information collected below is for our funder's demographic data collection purposes for research and evaluation. We enter your information onto the Department of Social Services (DSS) database which is then deidentifed. You can find more information about the way DSS use this information at: dss.gov.au/privacy-policy and how we manage it on the EACH webiste at each.com.au

Please respond to the questions below:

I acknowledge that I have read and understand the information outlined above and give my consent to collect and use my personal information as stated.

YesNo

I consent to being contacted in the future for surveys, research or evaluation exercises.

YesNo

Residential Accommodation

If other, (please specify)

Dependent Children

Living with dependent childrenNot living with dependent childrenOther

If other, (please specify)

Do you have one or more of the following conditions or disabilities? *

Indigenous Status *

NoAboriginalTorres Strait IslanderAboriginal and Torres Strait Islander

Main Source of Income - please select

Nil Income Govt payment/pension/allowancesEmployee/Salary Wage Self Employed (unincorporated business income)Other income (incl. super/other investments)

We may need to follow up some information with regard to your application with lawyers, services, doctors etc. who you may have detailed in the application. If you do not object to this please sign where indicated.

I authorise a Children's Contact Service staff member to contact any agency or person who has been detailed herein to follow up information in this form.
I also confirm that all information herein is current and correct to the best of my knowledge.

Signed

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Date

Children's Contact Service - Application Form

LIST NAMES OF BOTH PARENTS AND CHILDREN

SERVICE TYPE REQUESTED

YOUR DETAILS

The service is open for changeovers and supervised visits Thursdays-Sundays. Please select the days and time slots that you would be available (more than one can be selected)

LEGAL REPRESENTATION

OTHER PARENT'S DETAILS

Client Consent

WE ASK THAT THIS FORM BE SIGNED BY THE APPLICANT RATHER THAN AN ADVOCATE IN ORDER TO VERIFY THEIR AUTHORISATION OF IT'S CONTENT