ANGLICAN CHURCH DIOCESE OF SYDNEY

REQUEST FOR PASTORAL CAREAND ASSISTANCE

1.PERSONAL DETAILS

I, ______

(Please insert full name)

of ______

(Address)

______

(Date of birth)

request financial assistance from the Pastoral Care and Assistance Scheme for child abuse / sexual abuseby a church worker of the Sydney Diocese against me.

2.CIRCUMSTANCES OF THE REQUEST

a)This request arises from my complaint made under the Discipline Ordinance 2006made on the following date: ………………………………………….. .

OR

b)I attach:

  • a Statutory Declaration dated …………………………………………..OR
  • other document …………………………………………..

setting out my disclosure.

Please list the documents (if any) provided in support of this request for Pastoral Care and Assistance:

  1. ______
  1. ______
  1. ______
  1. ______
  1. ______

NOTE:

You do not have to fill out all of this form to request financial assistance, apart from your personal details above and your signature on the last page. However, the more information we have, the easier it will be to assess your application.

Pleasecomplete the following sections if these matters are not included in detail in your complaint or statutory declaration / other documents attached.

3.EFFECTS OF ABUSE

(Please attach any supporting medical or psychological reports)

(a)Psychological or psychiatric effects (please describe any psychological or psychiatric injuries and/or conditions sustained).

______

______

______

______

______

(b)Physical injuries (please describe any physical injuries sustained).

______

______

______

______

______

(c)Impact of the events (please describe what the impact of the abuse on you has been)

______

______

______

______

______

(d) Future needs (please describe what needs you have which arise from the abuse).

______

______

______

______

______

[Please attach further page/s if more space required.]

4.PECUNIARY LOSS

(Please attach the originals of any documents, medical reports, certificates, receipts which substantiate this request for financial assistance).

In the space below please identify:

(a)Details of any medical, pharmaceutical, counselling or other treatment expenses. (Please itemise those expenses paid by Medicare, or your private health insurer or by yourself).

(b)Details of the cost of travel for required medical treatment.

(c)Details of any other costs incurred (including the cost of medical or psychological reports obtained in support of the request).

(d)Details of any loss of income or opportunityfor employment arising from any total or partial incapacity to work.

______

______

______

______

______

______

______

Sign below once you have completed this application, then post to the address below together with any supporting documentation. You will be notified if any further action, information or documentation is required in order for your application to be assessed.

……………………………………………………………………………………

SignatureDate

……………………………………………

Name

After completion post to:Professional Standards Unit

Anglican Church Diocese of Sydney

PO Box Q412

QVB Post Office

NSW 1230

Request for Pastoral Care & Assistance – 09/2012 Page 1 of 3