Family Violence Flexible Support Packages Application Form

Date application submitted: / /2017

Family Violence Flexible Support Packages Application Form

Purpose: This application is to be used by all case managers who are applying for a flexible package on behalf of their clients. This application will be processed by the FV FSP Coordinator at , ph 8470 9999.

1.  General Information

Client Name: / FV FSP No. (Office Use Only) :
FSP Total Allocation (Office Use Only):
$
DOB: / Ph: / No. of accompanying children:
ADDRESS:
Postcode: / Banyule ☐ Whittlesea ☐
Darebin ☐ Yarra ☐
Nillumbik ☐
Is the package for a dependent child?
Y ☐ N ☐ / Has the applicant received a package previously?
Y ☐ N ☐ If Yes number of packages:
Interpreter Required:
Y ☐ N ☐
Language: / Gender:
Female ☐ Male ☐ Non-binary ☐
Transgender ☐ Other:
Priority:
RAMP ☐ Non-RAMP high risk ☐ Low/medium risk ☐ / Perpetrator:
Intimate partner ☐ Child ☐
Other:
Please attach the following information:
·  Client Consent form

2.  Client Eligibility

Client must satisfy 2.1 and 2.2, and either 2.3 or 2.4 / Yes
2.1 The client has a case management plan in place, clearly identifying how the package will support their long term safety, health and wellbeing; AND / ☐
2.2 The clients safety and security needs, and independent living goals can be reasonably met through the provision of the package; AND / ☐
2.3 The victim/survivor has recently left an abusive situation; / ☐
OR
2.4 The victim/survivor is planning to leave an abusive situation or have the perpetrator removed from the home with appropriate legal sanctions in place. / ☐

Case Management/Planning

Please provide or attach a summary of case plan below. Please include short-term and medium-term goals:

Date plan signed:
Anticipated review date:
Is there a current case management plan/support plan for the children? ☐ Yes
Please provide or attach a summary of the case plan below. Please include short-term and medium-term goals specific to the children:
Date plan signed:
Anticipated review date:

A comprehensive family violence risk assessment (preferably CRAF) is a requirement to be eligible for the flexible support packages. Please attach completed risk assessment summary, or take the time to complete the one below:

Presence of factor
Risk factors for victims / Yes / No / Comments
Pregnancy/new birth* (if female)
Depression/mental health issue
Drug and/or alcohol misuse/abuse
Verbalised or had suicidal ideas or tried to commit suicide
Isolation
Risk factors for perpetrators
Use of weapon in most recent event*
Access to weapons*
Has ever harmed or threatened to harm victim
Has ever tried to choke the victim*
Has ever threatened to kill victim*
Has ever harmed or threatened to harm or kill children*
Has ever harmed or threatened to harm or kill other family members
Has ever harmed or threatened to harm or kill pets or other animals*
Has ever threatened or tried to commit suicide*
Stalking of victim*
Sexual assault of victim*
Previous or current breach of Intervention Order
Drug and/or alcohol misuse/abuse*
Obsession/jealous behaviour toward victim*
Controlling behaviours*
Unemployed*
Depression/mental health issue
History of violent behaviour (not necessarily family violence)
Relationship factors
Recent separation*
Escalation—increase in severity and/or frequency of violence*
Financial difficulties

How has family violence impacted on the safety, stability and wellbeing of your client and any children in their care (e.g. number of family violence incidents, number of times client had previously left the perpetrator, police interventions, L17s, IVOs, referrals to RAMP, stays in refuges, family violence services involvement etc)? Please include past and present family violence incidents and the responses/supports provided:

Details:

3.  Applicant Information

Residency Status:
Living in Australia ☐ Partner provisional visa ☐ Family member ☐
Australian resident ☐ Temporary protection visa ☐ Other:
Current housing type:
Emergency ☐ Refuge/crisis accommodation ☐ Public housing ☐
Private rental ☐ Home owner ☐ Homeless ☐
Other:
Income source:
Wages ☐ Government payment ☐ Mixed ☐
No income ☐ Other:
Country of birth: Australia ☐ Other:
Yes / No / Not known / Comments
Aboriginal or Torres Strait Islander / ☐ / ☐ / ☐
CALD / ☐ / ☐ / ☐
Disability / ☐ / ☐ / ☐
LGBTI / ☐ / ☐ / ☐
Mental illness / ☐ / ☐ / ☐
Pregnant / ☐ / ☐ / ☐
Child protection involved / ☐ / ☐ / ☐ / Involved in past ☐
Substance abuse / ☐ / ☐ / ☐ / Alcohol ☐
Other drugs ☐
Victoria Police involvement (L17/other) / ☐ / ☐ / ☐ / I/V Order type & expiry date:
Current Family Law Court Order/s / ☐ / ☐ / ☐ / Access arrangements (if applicable):

4.  Dependent Children

Details of each child:
Name:
Age/DOB/Gender:
Name:
Age/DOB/Gender:
Name:
Age/DOB/Gender:
/ Name:
Age/DOB/Gender:
Name:
Age/DOB/Gender:
Name:
Age/DOB/Gender:
Total number of dependent children:
Total number of dependent children in each bracket:
0-12 mnths: / 12 mnths-5yrs: / 6-12yrs: / 13-18yrs:
Yes / No / Not known / Comments
Aboriginal or Torres Strait Islander / ☐ / ☐ / ☐
Disability / ☐ / ☐ / ☐
CALD / ☐ / ☐ / ☐

5.  Financial

Is the client linked with a financial counsellor? / ☐ Yes
☐ No / If Yes, what actions have already been taken and what actions are planned?
If No, has a referral to financial counselling been made?

Please note, it is an expectation that all other reasonable avenues of financial/material support have been exhausted before applying for a flexible package – as per the Guidelines and in line with the funding agreement. What avenues have you and/or your client tried to source financial assistance elsewhere for the needs identified in your client’s case management/support plan and what assistance has already been received? – Please tick:

☐ Centrelink (See: http://www.humanservices.gov.au/)
(http://www.humanservices.gov.au/customer/subjects/domestic-and-family-violence)
☐ DHHS Concessions and Entitlements (See:
http://www.dhs.vic.gov.au/about-the-department/documents-and-resources/reports-publications/victorian-concessions
☐ Federal Court Support (e.g. SCCB) (See: http://www.humanservices.gov.au/customer/forms/fa023)
☐ Victims Assistance (See: http://mchs.org.au/services/services-for-adults/victims-assistance-program/)
☐ Gamblers Help (See: http://www.gamblershelpnnw.org.au/our-services/get-financial-support/)
☐ Berry Street (See: http://www.berrystreet.org.au/FamilyViolence)
☐ North Eastern Financial Counselling Program (See:
http://www.kildonan.org.au/programs-and-services/financial-support/financial-counselling/north-eastern-financial-counselling-program/)
☐ Haven; Home, Safe (See:
http://www.havenhomesafe.org.au/housing)
☐ Other/s (Family Services packages, NILS – No interest Loan Scheme, Local government programs, relief centres, WIRE, URG –Utility relief grants, Private rental brokerage, etc…)
Type of assistance required / Description of items/expenditure
* Please Tick / Amount required ($)
Freedom from abuse and violence / Mobile phone ☐ / $
Personal alarm ☐ / $
Safety card ☐ / $
CCTV ☐ / $
Property alarm ☐ / $
Sensor lights ☐ / $
Windows ☐ / $
Fence ☐ / $
Security doors ☐ / $
Change locks ☐ / $
Other: / $
Suitable and stable housing / Repairs to property damage ☐ / $
Travel costs to move to a safe location (flights, travel) ☐ / $
Payment for short-term or emergency accommodation ☐ / $
Relocation and moving costs (incl. cleaning previous house) ☐ / $
Whitegoods ☐ / $
Furniture ☐ / $
Household items eg. cutlery, bed linen, etc. ☐ / $
Utility bills ☐ / $
Mortgage costs ☐ / $
Rent payment ☐ / $
Bond ☐ / $
Payment for short-term or emergency accommodation ☐ / $
Other: / $
Adult client's physical and mental health and wellbeing / Medical, pharmaceutical costs not covered by Medicare or PBS ☐ / $
Disability aids and equipment ☐ / $
Material needs and aids ☐ / $
Other health or wellbeing services ☐ / $
Dependent children's physical and mental health and wellbeing / Medical, pharmaceutical costs not covered by Medicare or PBS - dependent children ☐ / $
Disability aids and equipment ☐ / $
Material needs and aids ☐ / $
Other health or wellbeing services - dependent children ☐ / $
AOD counselling / Adult ☐ Provider: / $
Child ☐ Provider: / $
FV counselling / Adult ☐ Provider: / $
Child ☐ Provider: / $
Participation in learning and education (adult) / Course fees - TAFE, Uni, vocational training ☐ / $
Books, equipment and material aids ☐ / $
Support for travel ☐ / $
Other: / $
Type of assistance required / Description of items/expenditure
* Please Tick / Amount required ($)
Participation in learning and education (dependent children) / Childcare costs ☐ / $
School/education costs (eg. Fees, excursions, etc) ☐ / $
Books, equipment, uniforms and material aids ☐ / $
Support for travel ☐ / $
Other: / $
Participation in workforce / Clothing, uniform, tools and equipment ☐ / $
Training costs ☐ / $
Support for travel ☐ / $
Other: / $
Financial security and independence / Material needs ☐ / $
Payment of debts ☐ / $
Financial counselling ☐ Provider: / $
Financial services ☐ / $
Other professional services ☐ / $
Other: / $
Legal and court costs (Financial security and independence) / Legal services ☐ Provider: / $
Court costs ☐ Provider: / $
Other: / $
Support for social engagement, connection with culture and identity (adult) / Car repairs ☐ / $
Driving lessons ☐ / $
Travel card ☐ / $
Participation in social activities ☐ / $
Participation in cultural activities ☐ / $
Participation in sporting activities ☐ / $
Culturally specific professional services ☐ / $
Culturally specific services ☐ / $
Culturally specific activities ☐ / $
Other: / $
Support for social engagement, connection with culture and identity (children) / Car repairs ☐ / $
Driving lessons ☐ / $
Travel card ☐ / $
Participation in social activities ☐ / $
Participation in cultural activities ☐ / $
Participation in sporting activities ☐ / $
Culturally specific professional services ☐ / $
Culturally specific services ☐ / $
Culturally specific activities ☐
Other:
TOTAL FUNDING REQUIRED / $

6.  Client Outcomes

Clearly articulate how the Flexible Support Package will assist the client to achieve goals and outcomes. (Maximum 500 words)

7.  Referring Agency 8. Referring Worker

Organisation: Name:

Address: Phone:

Phone: Email:

Please take the time to read the FSP Guidelines for Professionals and complete the checklist below. Please ensure the eligibility criteria have been completed before submitting.
Yes / No
Does the referrer accept the conditions of this application as detailed in the FSP Guidelines for Professionals? / ☐ / ☐
Has the client provided consent for this information to be shared with Anglicare for the purpose of this application (and attached a signed consent form)? / ☐ / ☐
Does this application meet the eligibility criteria as outlined in the FSP Guidelines for professionals? / ☐ / ☐
Has a full risk assessment been conducted together with the client? / ☐ / ☐
Will the referrer provide case management support to the client? / ☐ / ☐
Is there a detailed case management plan in place? / ☐ / ☐
Have all other available resources been sourced prior to this application? / ☐ / ☐
Does the referring agency agree to provide reporting/feedback of outcomes as described in the FSP Guidelines for Professionals? / ☐ / ☐
Has the client provided consent to be contacted by Anglicare for the purposes of outcome evaluation? / ☐ / ☐
Does the referring agency agree to participate in FSP evaluation processes when developed by DHHS? / ☐ / ☐

Please submit the completed application form and supporting documentation via EMAIL to:

. Please cc in your Team Leader/supervisor and mark Confidential Application for FVFSP in the subject line.

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