Personal Information Name * Date *
Date Format: DD slash MM slash YYYY
Housing type Housing type Private Public Community Refuge/Emergency Accommodation Couch Surfing Sleeping Rough Other Language spoken at home Do you require an interpreter? Do you require an interpreter? Yes No Country of birth ATSI ATSI Yes No Details of any disabilities Age Age Under 25 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75 years or over Sex Sex Male Female Non-Binary/Other Paid Work Paid Work Full-time Part-time Casual No Income Bracket Income Bracket Less than $51,903 More than $51,903 Occupation Occupation Employed Self-employed Student Home Duties Carer Pension Retired Shift Work Volunteer Not Stated 1. Voluntary
I have chosen to engage with CRS on a voluntary basis. I am free to discontinue contact with CRS at any time.
Please Select * 2. Own Decisions
I am able to make decisions for myself and can choose to agree or disagree to any discussions and proposals discussed at any stage. Should this change at any time for me, I agree to inform the CRS.
Please Select * 3. Good Faith
I am entering into this dispute resolution process in good faith with a genuine desire to discuss, negotiate and find resolution to the dispute. Should this change for me at any time I agree to inform the CRS.
Please Select * 4. Role of CRS
CRS Staff/Mediators will not decide for me what I should and should not do, what to agree or disagree with, and will not make any judgements or recommendations about the merit of respective positions and points of view. For example, CRS cannot advise on legal matters or make an assessment of who is right or wrong in the dispute.
Please Select * 5. CRS Delivery of Services
I understand that at any time the CRS may choose to:
• Withdraw from offering services to either one or both parties.
• Postpone or cancel any stage of the process.
As far as is practicable, the CRS will discuss the reasons why these decisions may be made by the service and may include, but not be limited to:
• Health and Wellbeing (including psychological) of party/ies.
• Additional information being required by party/ies.
• Party/ies status in relation to the above requirements of Voluntary, Own Decisions and Good Faith has/have changed.
• Non-payment for services (only where applicable). Please Select * 6. Agreement
I understand that any agreement made by me and the other party/ies as a result of my engagement with the CRS, is not in itself legally enforceable. I can, with the agreement of the other party, and where legally possible, seek to have all or some of these agreements made into legal orders, however, this is subject to my own legal advice external to the CRS.
Please Select * 7. Fees
The CRS has informed me of any applicable fees and charges I may incur as part of my engagement with the CRS. I understand that any fees charged by CRS for mediation will be invoiced and that this invoice needs to be paid by me two days before mediation will be commenced.
Please Select * 8. Party/Client Confidentiality
I agree that I will not disclose any information obtained during my engagement with the CRS, about the issues and/or any other party/ies, unless:
• Required to do so by law.
• All parties agree to the disclosure.
• To obtain further legal, medical, or psychological advice.
• To a person within my field of intimacy with whom I would normally debrief (e.g. spouse/partner, family member)
I agree not to make any audio or visual recordings during my contact with the CRS during any part of the process. I agree that any notes I take are for my own use to remind me of discussions, and that these notes will not be used in any legal or similar proceedings as evidence. Please Select * 9. Audio and/or Visual Sessions
I understand that stages of the process between myself and CRS may be conducted via audio and/or visual technology, including by phone and online platforms, such as ‘Zoom’. When participating and/or otherwise engaging with CRS via audio and/or visual platforms:
• The CRS will invite me to participate by audio and/or visual platforms, only where CRS have determined that is appropriate to do so. I understand that CRS may decide to terminate audio and/or visual sessions at any time, if it is determined that the matter is, or has become, inappropriate to continue via an audio and/or visual platform.
• Where technical problems may occur, including if the audio and/or visual connection is not sufficient to support the session, CRS will advise me of an alternate method of completing the session.
• Sessions conducted via audio and/or visual technology will not be the same as an in-person session. I also understand that, in order to have the best results for the session, I should be in a quiet place, free from outside distractions, turn off my mobile phone, close other programs on my devices and “arrive” to the session on time.
• I will conduct the session in a private environment, where the session can not be overheard or interrupted by third parties. This includes ensuring that no other person or third party is physically present, or in hearing of the session except as otherwise permitted, for example, a previously agreed support person.
• I will immediately advise CRS if I become aware that any other person is present during the session or if any other person may have inadvertently overheard a session. I understand that CRS may need to notify the other party/s that this has occurred.
• I will not make any audio and/or visual recordings during my contact with the CRS during any part of the process. I understand that the same confidentiality protections and limits to confidentiality apply to audio and/or visual platforms as they would to an in-person session.
• I understand the potential risks to the use of technology, which may include interruptions, unauthorized access, and technical difficulties. I acknowledge that it is not possible for CRS to guarantee that any technology utilised in the sessions are 100% secure and/or confidential.
• Any sessions conducted by audio and/or visual technology are paid at the same rate as in-person sessions, or as quoted to me in writing, and that the Cancellation Policy, including Cancellation fees apply. Please Select * 10. CRS Confidentiality
CRS will keep confidential everything said during all communications with me and all other parties during each Stage unless CRS is:
• Professionally obliged to do so by law, or;
• I agree.
Instances may occur where CRS may need to disclose information to external agencies or individuals if there is a concern that a person’s life, safety and/or property is under serious and imminent threat.
Specifically, in regards Minors (children and young people under 18yo)
• A party discloses child abuse/neglect which could be classed as endangering the child. This also includes the child’s exposure to sexual activities, neglect both physically and mentally (for instance due to guardian/carer being under the influence of drugs/alcohol), physical and mental abuse such as in instances of Family and Domestic Violence.
• Where CRS assesses an adult potentially aiding and abetting a minor to breach a legal order which has been put in place to protect the minor.
Agencies CRS would consider reporting to include, but are not limited to, the AFP, Child and Youth Protection Services, Youth Justice, Crisis Assessment and Treatment Team (for crisis mental health assistance).
CRS endeavours to discuss its requirement to report to another agency with the party/ies in the first instance. However, CRS’s decision to fulfil its legal and ethical obligations to report in the above circumstances will not be based on whether the party/ies give permission. Please Select * 11. Disclosure
Sometimes other services may want to know how my contact with CRS is going. As with ‘Confidentiality’, CRS will not disclose any details and content of discussions they have had with me except for the reasons under part ‘e’.
As with Confidentiality, CRS will not disclose the details of discussions with me or anyone else who may have a stake in the dispute, without my permission. I understand; however, CRS reserves the right to update each stakeholder to the dispute on ‘process’ timelines and individual engagement with the process.
For instance, a referrer (such as the Court, Solicitor, CEO, Support Service, Employer) may require an update on whether an employee/client has attended their interviews with CRS, participated in coaching sessions, set a date for mediation, whether an agreement was reached at mediation (but not the content) and/or where there are delays in moving the process forward, reasons for these delays etc. CRS classifies this type of information as ‘process’ requests.
Please Select * 12. Legal Proceedings
Anything which is said or done during any ‘Stage’ of the process cannot be utilised as part of any legal proceedings, unless all parties agree, or it is required by law. I agree that I will not engage the CRS, its employees, or records, as part of any current or future legal proceedings.
Please Select * 13. CRS Service Charter
CRS staff members will treat me with respect at all times and will fulfil their professional responsibilities to ensure that my needs are met to the best of their capabilities. Equally, I will also treat CRS staff members with respect at all times and demonstrate this through my communication and actions when I come into contact with CRS employees. I understand that should my behaviour become inappropriate or aggressive towards any CRS staff member, the CRS may withdraw services.
Please Select * 14. Feedback
CRS is committed to providing the best possible services for my situation and welcomes and encourages my feedback on any aspect of my interaction with CRS. Should I have feedback about the services I have received, I am able to verbally or in writing, provide my comments to the CRS. Should I wish to lodge a complaint about the services CRS has provided, I am able to complete and submit a CRS Complaint Form for the CRS to review my complaint and provide me with an outcome.
Please Select * 15. Access to CRS information
CRS will make available for me any documents related to this Consent Form such as National Mediator Accreditation Standards, CRS Service Charter, CRS Feedback/Complaints Mechanism, all of which are also available at www.crs.org.au.
Please Select *