Family Connection Centre Application Form

You will not be excluded based on the information you share with us; however, failing to provide necessary information may result in services being declined or ceased.

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.

Please note: this is an application for the Full Fee for Service Program. Should you wish to apply for the Children's Contact Service, (a co-contribution, low fee Contact Service), please complete the CCS Application form here: Childrens Contact Service Application Form

Please select the Service Type Required *

Supervised VisitSupervised Changeover

Does the child live with you? *

Yes No

What is your relationship to the child? *

MotherFatherCarerOther

If other, please provide details

Have you used a Children’s Contact Service for Supervised Visits / Changeovers previously? *

YesNo

If yes, advise which service have you used, and when did you last use this service?

Your Details

First Name *

Last Name *

Gender *

Date of Birth *

Address *

Street address: *

Suburb: *

State: *

Postcode: *

Phone Number *

Can we send reminder SMS’s to this number? *

Email Address

Can we send confirmations, letters and schedules to this email address? *

YesNo

Country of Birth *

Are you of Aboriginal or Torres Strait Islander origin? *

Main Language Spoken *

Do you require an interpreter? *

YesNo

If the main language you speak at home isn’t English, please rate your ability to speak English *

Do you feel you need support from another person to engage with this service?

YesNo

If yes, please provide details

Household Composition

Residential Accommodation *

Dependent Children *

Main Source of Income *

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

The other Parent/Guardian/Carer’s details

First Name *

Last Name *

Gender

Date of Birth

Address

Street address

Suburb

State

Postcode

Country of Birth

Main Language Spoken

Relationship to the Child/ren *

If other, please specify

Child’s Details

Child/ren’s details –tell us about each child attending the service. If more than one child is attending, select 'Add additional child' below.

For Visiting Parent Only

Are you the visiting parent? *

When was the last time you had contact with the child/ren?

How often does contact occur?

Where has contact been occurring?

Is this contact supervised?

YesNo

For Both Parents/Guardians to complete

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

Are there any Parenting Orders / Family Court Orders / Federal Magistrate’s Court orders? *

YesNo

Please Attach a Copy of Court Orders / Agreement Documents

Browse

When is the next court hearing?

Is there a current Intervention Order / Family Violence Order in place? *

YesNo

ATTACH IVO/FVIO

Browse

Legal and Court Information

Do you currently have legal representation?

YesNo

Representation Name

Address

Street address

Suburb

State

Postcode

Phone Number

Email Address

I give consent for Family Connection Centre Staff to speak to my nominated legal representative as required

YesNo

Please note: Inclusion of legal representatives details will indicate consent for staff to speak to the lawyers about the case, unless clearly stated otherwise.

Has an Independent Children’s Lawyer been appointed?

YesNo

Lawyers Name

Lawyer's Address

Street address

Suburb

State

Postcode

Phone Number

Email Address

I give consent for Family Connection Centre Staff to speak to my nominated legal representative as required.

YesNo

Please note: Inclusion of Independent Children’s Lawyer details will indicate consent for staff to speak to the lawyers about the case, unless clearly stated otherwise.

Child Protection Involvement

Is there current Child Protection Involvement? *

YesNo

Protective Worker's name *

Office Involved *

Phone Number *

Nature of involvement and outcome (if applicable)

Please select the days and time slots that you would be available for Supervised Visits / Changeovers (more than one can be selected)

Of the days selected please indicate your preferred day and time.

Financial Responsibility

The distribution of financial responsibility has been determined by? *

Parenting PlanFamily Law Court OrderParental Agreement

Parent 1 (lives with Parent) is responsible for the following amount of the Supervised Visitation Fees. *

Parent 2 (visiting Parent) is responsible for the following amount of the Supervised Visitation Fees. *

Do you have any comments regarding the payment agreement?

CLIENT CONSENT

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 website at each.com.au

As part of Each’s commitment to provide a safe environment for you, your family and our staff, Each uses CCTV technology at the Family Connection Centre, 46 Warrandyte Road, Ringwood, VIC.

The CCTV system in place records vision and NOT sound. The recorded footage is retained for 30 days before being deleted. Only in exceptional circumstances where an incident occurs during a supervised visit, will the recorded footage be saved. This will be saved in compliance with all relevant legislation and record keeping laws.

We do not accept displays of aggression, threats or any behaviour that may be perceived as threatening or inappropriate towards the other parent, children, FCC staff, or any other person at the service. FCC will not tolerate violence, abusive behaviour (including verbal abuse), the adverse effects of alcohol or drugs.

The FCC retains an absolute statutory and operational right to refuse, suspend, or terminate service to any family where risk cannot be safely managed.

You will receive a copy of the Family Connection Centre, Terms and Condition upon acknowledgement of your application.

I have read and understood the 'What it costs section' Family connections centre - Each *

I acknowledge that I have read and understood the information outlined above regarding, behaviour, service usage and CCTV . *

YesNo

I give my consent to collect and use my personal information as stated. *

YesNo

We may need to follow up on 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 Family Connection Centre 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 *

Draw signature|Type signatureClear

Date *

Family Connection Centre Application Form

Your Details

The other Parent/Guardian/Carer’s details

Child’s Details

Child/ren’s details –tell us about each child attending the service. If more than one child is attending, select 'Add additional child' below.

For Visiting Parent Only

For Both Parents/Guardians to complete

Legal and Court Information

Child Protection Involvement

Please select the days and time slots that you would be available for Supervised Visits / Changeovers (more than one can be selected)

Financial Responsibility

CLIENT CONSENT

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

This form will be removed from FCC records after 12 months if service provision has not commenced.