CFS - Strong Families

Martinthi - Strong Families Strong Communities Referral

The aim of the program is to support families with children by addressing low to medium safety concerns early in their journey, de-escalating child protection involvement, and addressing the needs of children and their families.

Are any of the following concerns currently impacting your family? *

Please provide details. *

Date of referral *

I am *

a parent/carera family or community membersomeone who works in a government or non-government agency

Has the parent/carer given consent for referral and engagement?

YesNo

About the referrer

Referrer's name *

What is your relation ship to parent/carer?

Referrer's email *

Referrer's phone number *

Agency (where applicable)

Referrer's role

What service do you provide to the family?

Please provide details *

About the primary caregiver

Name *

Date of birth *

Age in years *

Address *

Post code *

Phone - Mobile *

Email Address *

What is your cultural identity? *

AboriginalTorres Strait IslanderBothNeither

CALD *

YesNo

Cultural background

If yes, is an interpreter required? *

YesNo

If yes, which language?

Do you identify as living with any disability? *

YesNo

Provide details

List all the children that live with you

About the family

Please specify

Is your current living arrangement adequate to your needs *

YesNo

Is your accommodation at risk? *

YesNo

Please specify

About primary care givers' relationships

Have you or are you currently experiencing domestic and/or family violence? *

YesNo

Is there a current Intervention Order in place?

YesNo

Please provide details

Alleged perpertrator's details (if known)

Name

Date of birth

Alleged perpetrator's relationship to the primary care giver

Last known address

Is there a safety plan in place?

YesNo

Please provide details

About the primary care giver's health & financial wellbeing

Health

Who are your support people? *i.e. family, friends, community groups e.g. church

Do you have a current GP or other workers who support your health? *

YesNo

(e.g. GP, counsellor, MH worker etc.)

Please specify

Do you currently use any drugs or alcohol? *

YesNo

Are you looking for support to manage your substance use?

YesNo

Have you ever been diagnosed with a mental illness? *

YesNo

Please specify

Financial wellbeing

Are you receiving a regular income? *

Yes - CentrelinkYes - Paid workYes - Centrelink and paid workNo

Provide details of type of income

Are you experiencing financial challenges in supporting your family's needs? *

YesNo

Do you think financial counselling would be helpful for you?

YesNo

List other adults (over 18) that live with you

List all other services supporting your family

e.g. community agencies, schools, GP, psychologists, counsellors, OT, speech pathologists, school's early childhood services, NDIS

Service name *

Type of support *

Contact person *

Phone *

Email *

Family member being supported *

What is working well for the family? *

What are your worries *

Is there anything else you would like us to know to assist with this referral?

UnitingCare Wesley Bowden Inc ABN 65 440 352 199

77 Gibson Street, Bowden SA 5007

Rev. 08/23 V1