CCS Intake Form - Relationships Australia Canberra & Region

- Step 1 of 9

SECTION 1: SERVICE/S REQUESTED

Please note that the Children's Contact Service requires both parents/carers to complete this form before an application can be progressed on the waiting list. Your response to this form will remain confidential and will not be visible to the other party.

At the end of this form you will be asked for the other party parent/carer's contact information.

I/We are seeking the below service/s (select all that apply) *

Change Over
Supervised Visit
Virtual Visit

Details of Children for Contact:

Name of Child 1 *

First

Last

Gender of Child 1 *

Date of Birth for Child 1 *

Add a second child *

Name of Child 2 *

First

Last

Gender of Child 2 *

Date of Birth of Child 2 *

Add a third child *

Name of Child 3 *

First

Last

Gender of Child 3 *

Date of Birth of Child 3 *

Add a fourth child *

Name of Child 4 *

First

Last

Gender of Child 4 *

Date of Birth of Child 4 *

Add a fifth child *

Name of Child 5 *

First

Last

Gender of Child 5 *

Date of Birth of Child 5 *

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SECTION 2: PERSONAL DETAILS: PARENT/CAREGIVER

Name *

First

Last

Date of Birth *

Address *

Postcode *

Mobile *

Home

Work

Email *

Confirm Email

Relationship to child/ren: *

Mother
Father
Other

Please describe relationship *

I am the parent/carer that the child/ren *

Lives with (at the address specified above)
Spends time with
Other

Please describe *

To help us coordinate your contact and keep you safe, please provide the information for your vehicle.

Car registration

Make, model & colour

Important: Please bring your Drivers Licence/Passport/Proof of Age Card to your first appointment. One of our team will sight this to verify your identity.

Previous service history

Have you previously used Relationships Australia Canberra & Region services?

Please detail approximate year and which service accessed

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SECTION 3: LEGAL & OTHER SERVICE INFORMATION

Legal Representative

Do you have a legal representative?

Name *

Phone Number *

Email *

Confirm Email

I give consent for CCS staff to speak to my nominated legal representative as required *

Do you have an independent children's lawyer

Independent Children’s Lawyer Details

Name *

Phone Number *

I give consent for CCS staff to speak to the Independent Children’s Lawyer as required *

Other Services involved (if applicable):

(support worker, caseworker, advocate, counsellors, etc.)

Name of worker

First

Last

Agency

Phone

I give consent for CCS staff to speak to the above nominated party as required

Do you need to add a second Service

Name of worker 2

First

Last

Agency 2

Phone

I give consent for CCS staff to speak to the above nominated party as required

Do you need to add a third Service

Name of worker 3

First

Last

Agency 3

Phone

I give consent for CCS staff to speak to the above nominated party as required

Involvement with the Department of Communities and Justice (DCJ):

Has there ever been Child Protection involvement *

When and what were the circumstances *

Is there current Child Protection involvement *

Case Worker *

Office involved *

Phone *

What was the outcome *

I give consent for CCS staff to speak to the DCJ Case Worker specified above *

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SECTION 4: CURRENT ARRANGEMENTS

Current Parenting Arrangements

Who referred you to the Children’s Contact Service *

I am the live with parent *

When was the last contact with your child/ren *

Currently, how often does contact occur with the 'spend time with' parent/carer *

Where has contact been occurring *

Is the contact supervised? *

By whom? *

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

Please specify *

When is the next court hearing? *

Please bring a copy of your Parenting Orders/Family Court Orders/Federal Magistrate’s Court Orders to your first appointment.

Is there a current Apprehended Violence Order /Apprehended Domestic and Family Violence Order in place *

What is your understanding of the conditions of the AVO/ADVO?

Please bring a copy of your Apprehended Violence Order/Apprehended Domestic and Family Violence Order to your first appointment.

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SECTION 5: DETAILS OF CHILD/REN TO USE THE CHILDREN’S CONTACT SERVICE

CHILD 1 DETAILS

Name *

First

Last

Country of Birth *

Main Language Spoken *

Is the Child of Aboriginal or Torres Strait Islander origin *

No
Aboriginal
Torres Strait Islander
Both

Does this child attend any of the following

Child Care
Kindergarten
Primary School
High School

Grade (if applicable)

Is your child up-to-date with immunisations *

Please bring a copy of your child’s immunisation certificate to your first appointment.

Does Child 1 have any of the following health issues

Toilet training
Epilepsy
Asthma
Allergies
Hearing Problems
Sight Problems
Regular Medications
Other

Details *

Does Child 1 have any of the following diagnosed health conditions

Autism
Developmental Delay
Speech Difficulty
Physical Disability
Intellectual Disability
Attention Deficit Hyperactivity Disorder
Other

Details *

Description of Child 1

Please attach a photo of Child 1

Click or drag a file to this area to upload.

CHILD 2 DETAILS

Name *

First

Last

Country of Birth *

Main Language Spoken *

Is the Child of Aboriginal or Torres Strait Islander origin *

No
Aboriginal
Torres Strait Islander
Both

Does this child attend any of the following

Child Care
Kindergarten
Primary School
Highschool

Grade (if applicable)

Is your child up-to-date with immunisations *

Please bring a copy of your child’s immunisation certificate to your first appointment.

Does Child 2 have any of the following health issues

Toilet training
Epilepsy
Asthma
Allergies
Hearing Problems
Sight Problems
Regular Medications
Other

Details *

Does Child 2 have any of the following diagnosed health conditions

Autism
Developmental Delay
Speech Difficulty
Physical Disability
Intellectual Disability
Attention Deficit Hyperactivity Disorder
Other

Details *

Description of Child 2

Please attach a photo of Child 2

Click or drag a file to this area to upload.

CHILD 3 DETAILS

Name *

First

Last

Country of Birth *

Main Language Spoken *

Is the Child of Aboriginal or Torres Strait Islander origin *

No
Aboriginal
Torres Strait Islander
Both

Does this child attend any of the following

Child Care
Kindergarten
Primary School
Highschool

Grade (if applicable)

Is your child up-to-date with immunisations *

Please bring a copy of your child’s immunisation certificate to your first appointment.

Does Child 3 have any of the following health issues

Toilet training
Epilepsy
Asthma
Allergies
Hearing Problems
Sight Problems
Regular Medications
Other

Details *

Does Child 3 have any of the following diagnosed health conditions

Autism
Developmental Delay
Speech Difficulty
Physical Disability
Intellectual Disability
Attention Deficit Hyperactivity Disorder
Other

Details *

Description of Child 3

Please attach a photo of Child 3

Click or drag a file to this area to upload.

CHILD 4 DETAILS

Name *

First

Last

Country of Birth *

Main Language Spoken *

Is the Child of Aboriginal or Torres Strait Islander origin *

No
Aboriginal
Torres Strait Islander
Both

Does this Child attend any of the following

Child Care
Kindergarten
Primary School
Highschool

Grade (if applicable)

Is your child up-to-date with immunisations *

Please bring a copy of your child’s immunisation certificate to your first appointment.

Does Child 4 have any of the following health issues

Toilet training
Epilepsy
Asthma
Allergies
Hearing Problems
Sight Problems
Regular Medications
Other

Details *

Does Child 4 have any of the following diagnosed health conditions

Autism
Developmental Delay
Speech Difficulty
Physical Disability
Intellectual Disability
Attention Deficit Hyperactivity Disorder
Other

Details *

Description of Child 4

Please attach a photo of Child 4

Click or drag a file to this area to upload.

CHILD 5 DETAILS

Name *

First

Last

Country of Birth *

Main Language Spoken *

Is the Child of Aboriginal or Torres Strait Islander origin *

No
Aboriginal
Torres Strait Islander
Both

Does this Child attend any of the following

Child Care
Kindergarten
Primary School
Highschool

Grade (if applicable)

Is your child up-to-date with immunisations *

Please bring a copy of your child’s immunisation certificate to your first appointment.

Does Child 5 have any of the following health issues

Toilet training
Epilepsy
Asthma
Allergies
Hearing Problems
Sight Problems
Regular Medications
Other

Details *

Does Child 5 have any of the following diagnosed health conditions

Autism
Developmental Delay
Speech Difficulty
Physical Disability
Intellectual Disability
Attention Deficit Hyperactivity Disorder
Other

Details *

Description of Child 5

Please attach a photo of Child 5

Click or drag a file to this area to upload.

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SECTION 6: SCHEDULE PREFERENCES

Allocation to a service will depend on receipt of parent/carer's application forms. Upon receipt of both applications, you will be required to attend a mandatory Registration and Information Session at the CCS. Children do not attend this session.

Supervised visits run for 2 hours on a fortnightly or monthly basis. The Children's Contact Service operates on strict time schedules and is by appointment only.

I am available for contact sessions at (select all that apply):

AM 10:00am - 12:00pm

Friday
Saturday
Sunday
Monday
Wednesday

PM 2:00am - 4:00pm

Friday
Saturday
Sunday
Monday
Wednesday

Is there any other information that we should be aware of in relation to you, the other parent/carer and/or your child/ren attending the Children’s Contact Service?

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SECTION 7: AGREEMENT & CONSENT

Acknowledgement and Consents

I acknowledge that the CCS is separate from the Family Law System, Family Court of NSW and Federal Circuit Court *

I understand the CCS are not a party to the contact orders, however the CCS works with Parents, Family members and Kin to help them meet these orders or agreements and to ensure that the interests of the children come first. *

I consent to Relationships Australia Canberra & Region contacting and receiving information from my lawyer for all matters regarding this case. *

I understand that I can withdraw my consent at any time. *

I certify that the information provided in this form is true and correct. *

Your Name *

Signature *

Clear Signature

I understand that the submission of my electronic signature will be accepted as a verified signature.

Date

Time

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SECTION 8: AGREEMENT & CONSENT

Thank you for completing you application.

To progress this application we will contact the second party on your behalf, to complete the application as well (if they have not already done so).

Please provide contact information for the other party parent/carer:

Name *

First

Last

Mobile *

Email *

Confirm Email

Relationship to Child/ren *

Mother
Father
Carer
Other

Please describe *

They are the parent/carer that the child/ren: *

Lives with
Spends time with
Other

Please describe *

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