Application for Payment Proforma

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					                Family Reconciliation Mediation Program
                Groupwork Brokerage Application Form

                          Overriding objectives of brokerage
1. Support wherever possible and appropriate young people to remain / return home;
2. Support young people to reconnect with family;
3. Support young people to resolve within themselves issues relating to family conflict /

                Groupwork Brokerage Application Requirements
1. The group program supports one or more of the above objectives
2. Young people in the group are aged between 15-25 and are linked into a SAAP service, a
   refuge, a THM provider or Creating Connections
3. There is not a group program already existing that is accessible
4. Applications that demonstrate collaboration with other agencies are looked upon
5. Applications that have either a direct or ‘in kind’ contribution are looked upon favourably

Date of Application:
Name of Organisation:
Program / Service:
Main Contact Person:                          Position:
Contact Person:                               Position:
Phone:                               Email:
Mobile:                              Fax:

Service Type:
   SAAP                Refuge        THM             Creating Connections               Other

If ‘Other’, are young people in the group linked to a youth housing program, or residing in
Transitional Housing?
           Yes, please provide details

Groupwork Details:

Title & type of group

Group aim, objectives and expected outcomes (Please include the explanation
of how these objectives or expected outcomes link to one or more of FRMP’s
brokerage objectives)

Participant details:

     Where will the participating young people be referred from

     Anticipated numbers of young people

     Gender of young people:

Groupwork implementation:

     Number and length of Groupwork sessions

     Facilitator(s) of the Groupwork

     Accreditations / qualifications of the facilitator(s)

     Contact number and email of facilitator(s):

     Venue of the Groupwork

Time lines:
     Expected Commencement date:
     Expected Completion date:

Checklist of the requirements for referring worker:
     I understand once the application is approved, I will be the main contact regarding this
application. I will contact the Groupwork facilitator(s) and the young people/ their families to
organise the Groupwork
     I will provide feedback to FRMP once the Groupwork is completed and will get the young
people / their families to provide feedback as well.
     I will forward the Invoicing Guidelines to the facilitator(s) once I receive the confirmation
letter from FRMP.
     I will contact FRMP ASAP if any of the following situations occur:
   If there is any change about the Groupwork
   If the Groupwork ceases
   If there are any difficulties / issues with the Groupwork
   If the Groupwork has not started within a month after the approval date

Name of the referring worker:                                 Date:

                           GROUP PROGRAM BUDGET
                                 ITEM                                     Cost (including
1. External staffing costs: (costs relating to outsourced or sessional
staff required for the proposed group)

2. Hire of Facilities: (Please detail facility requirements and
associated costs)

3. Equipment: (Please detail the costs for any required equipment)

4. Operating Expenses: (Cost associated with items such as travel,

5. Consumables: (Things associated with the direct delivery of the
program eg. food)

6. Other Expenses: (Please specify)

7. Total group program cost (add # 1-6)

8. Income provided by agency: (Not in kind contributions)

10. Contributions by young people: (if any)

11. Income provided by other funding bodies:

12. Total Income (add # 8-11)

Total amount requested from FRMP
brokerage funds (Subtract #12 from #7)
Details of in-kind contributions: (staff time, travel,                   Equivalent Expense
vehicle, use of facilities, equipment or supplies)                       ($)

The Application Process:
1. Contact the FRMP Brokerage Liaison Worker to discuss the application.
2. Fill in the brokerage application form (to be read in conjunction with the brokerage
      guidelines). These are both available on the FRMP website
3.    Fax or email the application to the Brokerage Liaison Worker
4.    The Brokerage Liaison Worker will inform the service as soon as a decision is made.
      FRMP endeavour to get back to applying service within 48 hours of receiving the
5.    Payment arrangements are flexible and will require discussion with FRMP. FRMP will
      make contact with applying service at the time of approval to discuss payment

Agency Requirements:
1.    To invoice FRMP as agreed
2.     ALL receipts MUST be kept and forwarded to FRMP, Melbourne Citymission
3.    To contact FRMP if the proposed group changes in any way or ceases.
4.    To provide feedback to FRMP as agreed (detailed in confirmation letter and Brokerage
      Guidelines). The Feedback and Groupwork Evaluation process not only offers workers
      and participants an opportunity to reflect upon the Groupwork, but also allows FRMP to
      gather important information about the success and challenges of Groupwork
      interventions within our sector. This is a key component of the Action Research model.
5.    Where Groupwork results in public displays such as exhibitions or performances, FRMP
      would welcome the opportunity to attend. Within all publications and performances,
      FRMP and Melbourne Citymission must be acknowledged.

Agency Obligations:
1. Duty of Care: the Grantee undertakes to ensure that all reasonable steps have been
      taken to avoid harm to all participants.
2. The Grantee is required to maintain appropriate insurance policies.
3. The Grantee must insure compliance with all relevant statutes, regulations, by-laws and
      requirements of any Commonwealth, State or Local authority and that all necessary
      requirements and approvals for the intervention/s are obtained.
4.    Grantee is responsible for ensuring funds are used for the original intended purpose.
5.    Funds will be directly transferred to services where this is available or directly to the
      brokered service. It is mandatory all financial protocols are adhered to and all mandatory
      paperwork is maintained and forwarded to FRMP, Melbourne Citymission (eg invoices,
      assessment forms and evaluation).

     Please email or fax marked confidential to Brokerage Liaison Worker

                          Fax number: 8625 4410


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