FRSC - Request for Service

Family Relationship Support for Carers

FRSC Service Eligibility

FRSC supports family members caring for someone with a disability. If you are a carer that fits FRSC eligibility criteria, please complete the form below.

If you are not a carer for someone with a diagnosed disability, please use links provided below to access other carer services that may be able to support you.

Carer gateway – www.carergateway.gov.au – 1800 422 737

Villa Maria – www.vmch.com.au 1300 650 615

Carers Victoria – www.carersvictoria.org.au – 1800 514 845

Well Ways - www.wellways.org – 1300 111 400

Tandem – www.tandemcarers.org.au – (03) 8803 5555

Mental Health and Wellbeing Locals - Better Health Channel

Who is completing this form? *

1. I am completing for myself2. I am completing on behalf of another person

If you are completing on behalf of another person, please advise your relationship to the applicant.

If you are completing on behalf of another person, please advise if the applicant consented to referral.

YesNo

We cannot accept this referral without confirmation of consent from the individual.

Please discuss with the carer and secure their consent before proceeding with another application.

You may now close this browser.

Thank you.

1. Request for Service

First Name *

Last Name *

Date of Birth *

If selected [I/They] use a different term please advise.

Current Address *

Street address *

Suburb/Town *

State *

Postcode *

Mobile Phone Number *

Home Phone Number

Email Address *

Do you identify as having a disability *

NoYes

If yes, please describe *

Are you Aboriginal or Torres Strait Islander origin *

AboriginalTorres Strait Islander BothNo

Countrybirth *

Date of arrival in Australia

Visa Type

Cultural background

Main language spoken at home *

Ability to speak and understand English

Very wellWellSlightlyNot at all

Need for Interpreter Services *

YesNo

Marital Status *

Living Arrangements *

Employment Status *

Government Pension Type *

If other, please specify

Do you have dependent children

YesNo

I acknowledge receipt of and understand the information contained in the following EACH brochures: *

View Customer Data Collection Information (select checkbox)

Customer Data Collection Information

The information that you provide on this form includes your personal information which is protected by the Privacy Act 1988. Full details of our Privacy Policy can be found on our website: www.each.com.au

Why are you asking me these questions? Your personal information collected in this form will be stored and shared by EACH and DSS database and with the relevant practititioner. The data is important, primarily for the following reasons:

It is a requirement of our funding body that we gather feedback for all services we provide at the beginning and throughout your journey with us.
Client satisfaction and achievement of goals is vital to our service delivery.
The data collected helps us understand the demographics such as age, gender and ethnicity; and respond to the customer needs appropriately.
It also makes the service more accessible to all customers, and helps us deliver good outcomes.

The Family Relationship Support for Carers (FRSC) is an EACH program funded by the Department of Social Services (DSS).

I acknowledge that the carer has received and understands the information provided.
I acknowledge that the carer has read, or I have read to the carer, and they agree to the Customer Data Collection Information. The carer consents to their details being shared for the purposes of receiving services. *

Signature *

Clear

Print Name *

Date *

2. Referral details

Who referred you to this service *

If other, please specify

How did you / they find out about us? *

Agency

Contact person

Position

Contact Number

Referrer Email

"Permission to contact this organisation / person regarding this referral"

YesNo

Please identify at least one goal that you hope to achieve as a result of this funding *

Changed behavioursChanged impact of immediate crisisChanged knowledge and access to informationChanged skillsEmpowerment, choice and control to make own decisionsEngagement with relevant support services

(choose at least one)

3. Customer Information Details

Who is the person you are caring for and what is the diagnosed disability? *

All Carers / family members that will engage in counselling, including yourself.

Name *

Date of Birth *

What is the main purpose that brought you to this service *

If other please advise

Do you have a Mental Health Care Plan

YesNoCurrent Plan Exhausted

Are you engaged with Carer Gateway? *

YesNoExhausted Counselling Allocation

Is your loved one in receipt of NDIS funding? *

YesNoIneligible

Details of preferred counsellor, if applicable

Name

Contact Number

Email Address

Please briefly describe your need for counselling to support your caring role. *

ADMIN USE ONLY:

FRSC Professional

Referred to

Date referred

Customer ID

Customer Case Code

Number of sessions approved

Date entered into DEX