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CHILD FIRST –North East Metro

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					                            CHILD FIRST –North East Metro
                                Ph: (03) 9450 0955      Fax: (03) 9456 9665
                                       Email: childfirst@cps.org.au
Professional & Family Referral Form
Child FIRST is a central intake and referral services for family support in the North East Metro
catchment, in the following Local Government areas. Child FIRST aims to provide access for family
support services, to vulnerable children, youth and families.
                Please complete this referral form electronically and fax to 9456-9665.
Darebin                  Yarra                   Banyule/Nillumbik                 Whittlesea

REFERRAL DETAILS:
Name of Referrer:                                     Date of Referral:

Professional Role:                                    Length of involvement
                                                      with family:
Address:

Phone number:                                         Agency:

Email:                                                Fax number:
                                         Yes      No      Unknown      Comment:

Is the family aware of the
referral to Child FIRST?
Is the family willing to engage
with a support service?
Is there a Mental Health service                                       Worker details:
provider currently involved with
the family?
Is there a Disability services                                         Worker details:
provider currently involved with
the family?
Is DoHS, Child Protection                                              Worker details:
currently involved with the
family?

FAMILY UNIT
Adult Members (Parent/Primary Care)
Name                             M/F      DOB           Relationship      Address & Contact Telephone Number




Children/young people

Name                             M/F      Age           Relationship      Address & Contact Telephone Number




Other family – kith and kin (if known including grandparents, neighbours and extended family)
Name                                   Relationship                       Address & Contact Telephone Number
CULTURAL IDENTITY

Do any of the family identify as Aboriginal /Torres Strait Islanders?                  Yes               No
Family member who identify as ATSI :

Family Cultural background:

Language spoken at Home:


Interpreter required:                         Yes            No             Unknown
Language spoken at home:
Ancestry the family identify with:



ALERTS      (Including any worker safety issues if known, dangerous behaviour/s etc)         Please X.

Violence in the family          Unknown                No            Yes          Type:
Weapons in the home             Unknown                No            Yes          Type:
Violence towards                Unknown                No            Yes          Type:
workers
Pets (dogs) at the home         Unknown                No            Yes          Type:
Substance use issues            Unknown                No            Yes          Type:


PROFESSIONAL NETWORK               (including schools, history of involvement)
    Service/Agency             Contact Person           Current Status –          Phone number                    Clients
                                                        active/pending/          /Contact Details              consent for
                                                             closed.                                          Child FIRST to
                                                                                                                 contact
                                                                                                                service?
                                                                                                              YES    NO

                                                                                                              YES    NO

                                                                                                              YES    NO

                                                                                                              YES    NO

                                                                                                              YES    NO



CONSENT

Has the client consented to the referral to Child FIRST?                                                       YES     NO


Does the client consent for Child FIRST to share information with involved                                     YES     NO
services/people?


Does the referrer consent to their identity being disclosed to the client, as the person                       YES     NO
who made the referral?




                                                                                                                       2
REASONS FOR REFERRAL; include ~ Relevant history, parents capabilities, all children’s safety
stability & development (includes risks & needs), family connections and resources, referrer’s contact
with family, concerns for the child/ren, what will the family gain from the service.




CURRENT SITUATION; include ~ what precipitated the referral to Child FIRST, relevant legal
involvement, circumstances that currently impact on the family and child/rens wellbeing.




KEY ISSUES TO BE ADDRESSED; include ~ views of family and the referrer.




Who referred you to Child FIRST?




Additional information to be considered for inclusion: (please attach)

      Family Genogram
      Case Conference Minutes

COMPLETED BY:
DATE:
                                                                                                   3
C




Child FIRST or NEMFS Agency Use Only


    REFERRAL CATEGORY                              Please X.

    Significant wellbeing concerns
    Complex
    Other / vulnerable




    REFERRAL PRIORITY                              Please X.

    Urgent
    Not Urgent




    REFERRAL OUTCOME                               Please X.

    Allocated NEMFS
    Agency:

    Date:

    Closed – referral to other service - Agency:
    Closed – information and advice
    Closed – no further contact




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