Family Support Program Referral Form - Conflict Resolution Service

Details of the Referrer

Referring Service

Name of referrer

Role of referrer

Phone

Email

Service provided to young person

Will your service have continued involvement with the young person and family?

Expectations of CRS service delivery/desired outcomes of program support

Date of Referral

Consent:

Has the young person consented to the referral?*

Has the young person consented to the referral?

Has the parent/carer consented to the referral?*

Has the parent/carer consented to the referral?

Details of Young Person

Please complete all the sections that you are able to. We recognise that some information will not be available for all families.

Name

Date of Birth*

Date of Birth

Gender or Pronouns

Address

Phone*

Phone

Email

Does the young person identify as culturally or linguistically diverse?

Country of Birth

Details of Parent or Carer

Parent or Carer Name

Date of Birth

Gender or Pronouns

Address

Phone

Email

Relationship to Young Person

Does the parent or carer identify as culturally or linguistically diverse?

Country of Birth

If yes, please provide details

Details of Additional Parent or Carer

Do you wish to add the details of an additional Parent or a carer?

Parent or Carer Name

Date of Birth

Gender or Pronouns

Address

Phone

Email

Relationship to Young Person

Does the parent or carer identify as culturally or linguistically diverse?

Country of Birth

If yes, please provide details

Presenting issues and support needs

Details about current conflict or risk. Please enter information about the family’s conflict and its impacts.

Historical information related to the family conflict and young person’s risk of homelessness.

Where is the young person currently living? Please also include information on any relevant family members.

Details of current and historical service engagement.

Current orders or upcoming court dates for the young person or family.

Current strengths of the young person or family.

Any other relevant Information.

How did you hear about CRS?

Do you know a family or young person in need of support to address conflict and rebuild relationships?

Family Support Referral Form

Details of the Referrer

Consent:

Details of Young Person

Details of Parent or Carer

Details of Additional Parent or Carer

Presenting issues and support needs