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Services
Knowledge Hub
- Guides & Downloads
Support Groups
Contact

Referral Form

Referral Form

If you prefer not to complete this form online, you can download a PDF referral form to fill out by hand. Completed forms can be dropped off at our Waratah centre or emailed directly to our intake team at reception@nfss.org.au.

Family Members

Member 1

Full Name

Gender

Role

Cultural background

Aboriginal

TSI

DOB

Member 2

Full Name

Gender

Role

Cultural background

Aboriginal

TSI

DOB

Member 3

Full Name

Gender

Role

Cultural background

Aboriginal

TSI

DOB

Member 4

Full Name

Gender

Role

Cultural background

Aboriginal

TSI

DOB

Member 5

Full Name

Gender

Role

Cultural background

Aboriginal

TSI

DOB

Member 6

Full Name

Gender

Role

Cultural background

Aboriginal

TSI

DOB

Member 7

Full Name

Gender

Role

Cultural background

Aboriginal

TSI

DOB

Member 8

Full Name

Gender

Role

Cultural background

Aboriginal

TSI

DOB

Family Members living in the home:

Emergency Contact

Would you like the Aboriginal Cultural Liaison Worker to be present at the initial meeting?

Yes No

Address

Phone

Email

Is an interperater needed?

Yes No

Interperater Details

Previous Client

Yes No

Previous Names

Do you or anyone in the home have a disability?

Intellectual learning disability Psychiatric disability Sensory/speech disability Physical/diverse disability Other disabilities No disabilities I prefer not to say

Do you have the use of a car?

Yes No

What is your main source of income?

Centrelink benefit Income from wages or business Private savings Income from family or friends Other

If other, please describe

Self referral?

Yes No

How did you hear about FSN?

Referrer organisation

Is the client aware of the referral?

Yes No

Contact person

Contact person phone

Contact person email

Reason/s for referral

Physical wellbeing Community participation Material wellbeing Mental wellbeing/health Family functioning Personal or family safety (including domestic & family violence) Money management Education or employment Age appropriate development

Which of the above is the main reason?

Event triggering referral

If domestic and family violence, have you done a DVSAT assessment?

Yes No

DVSAT score

Person using violence details

Is there an ADVO?

Yes No

Conditions/Expiry Date

Any upcoming court dates?

Family Law court?

Yes No

Is it safe to leave a message?

Yes No

Is person using violence in custody?

Yes No

Accessibility Concerns

Child Protection Concerns

Is the referrer aware of reports to Community Services of children from this family?

Yes No

If yes, give details:

Referring Agency's Involvement

Will the referrer have ongoing involvement with the family?

Yes No

If yes, what do they see as their ongoing role?

Would the referrer like to know the outcome of the referral?

Yes No

Is the family aware of everything that the referrer has disclosed in making the referral?

Yes No

If no, give details of what the family is not aware of and what the referrer would like the family worker to consider in relation to this information

Other agencies involved with the family:

Worker Safety

Are there any issues with this family that would affect worker safety?

Yes No

If yes, give details

Other Relevant Details

Feel free to contact us on 02 4926 3577 with any questions you have.

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(02) 4926 3577 reception@nfss.org.au Monday to Friday 9am-4pm

Family Support Newcastle would like to acknowledge the traditional custodians of the land where Family Support Newcastle provides services. We pay our respects to Elders past and present and the Aboriginal and Torres Strait Islander people with whom we work. We acknowledge that this land was never ceded. We are grateful for the care of the land that occurred historically and that we are able to work and live on this land now.

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