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INTAKE/REFERRAL FORM FOR PRIVATE AND FAMILY LAW COURT SERVICE REQUESTS

The parties must complete ALL negotiations, which may involve their legal representation. Family Konnect is unable to mediate between the parties, Once the parties have reached an agreement, the completed online Referral Form, along with a copy of the court order, any other relevant orders, and a copy of the payment receipt for the Intake fee ($110 per parent), should be submitted to Family Konnect.

(Court ordered supervised contact, introduction to child, history of mental health, substance misuse

INDEPENDENT CHILD/REN'S LAWYER (ICL)

If not applicable type N/A

If not applicable type N/A

If not applicable type N/A

PARENT DETAILS

If not applicable type N/A

If not applicable type N/A

If not applicable type N/A

Interpreter Required?
Yes
No

CHILDREN DETAILS

Names of Child/ren, Gender, D.O.B and any care needs such as Food allergies, Medical information or Behavioural issues

TYPE OF SERVICE REQUIRED:

Select from the following

ORDERS:

CONFIDENTIALITY

Can your contact details be known or given to the other party?
Yes
No

SUPERVISED TRANSPORT

Will the child/ren require transport by Family Konnect to and from the venue?
Yes
No
If yes, please specify the type of car seats are required

CHANGEOVERS

Will both parents be present at handover of the child/ren prior to the service start time?
Yes
No

ADDITIONAL INFORMATION

Intake Assessment and Its Purpose:

Before any service is accessed, both adults must have completed an intake assessment.

The purpose of the Intake assessment is:

● To identify supervision needs.

● To consider the nature and extent of any risk.

● To appraise whether the service has the capacity and resources to provide the required supervision.

● To provide a meeting for a full and frank exchange of information between the parties and this agency so that each can make an informed decision. The information exchange will include details of the service's purpose, duration, limitations, and costs of the services considered at these interviews, which will be issues around security arrangements, and the nature of that security will be identified. Data collection and limits to confidentiality will be discussed.

● Assess whether the proposed arrangements serve the interests of the child. I agree that the information provided in this form is correct. Any changes/ additional dates must be approved by both parties and sent in writing to Family Konnect.


Please send the intake fee of $110 per parent to the following bank account, make sure to include a reference with your family name so we know that the fee has been paid:


Family Konnect Pty Ltd

BSB: 067 873

Acc#: 12848854

PARENTAL SIGNATURE

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Date Of Signature
Day
Month
Year

Note: Service will not be able to conmmence until both parties have completed this form

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