Juvenile and Family Fire Awareness Program s1

Juvenile and Family Fire Awareness Program

PARENT / CARER REFERRAL

DFES Case Number: / Date received:
CHILD DETAILS
Name: / Gender:
Date of birth: / Age: / Ethnicity:
School: / Year at school:
Home address:
Parent / Carer Email Address:
Does the child have a learning or behavioural disorder? / Yes / No / Unsure
If yes, please specify: / Conduct disorder (CD)
Oppositional defiant disorder (ODD)
Attention Deficit Disorder (ADD)
Attention Deficit Hyperactivity
Disorder (ADHD)
Autism Spectrum Disorder
Asperger’s Syndrome
Deaf or Hearing Impairment
Learning Disability
Is the child medicated? / Yes / No / Unsure
Has the child previously been involved in the JAFFA Program? / Yes / No / Unsure
If Yes: / When?
FAMILY DETAILS
Primary care giver 1
Name: / Phone number:
Relationship to child: / Mother Father Other (please specify):
Primary care giver 2
Name: / Phone number:
Relationship to child: / Mother Father Other (please specify):
Marital status: / Single Married/De facto Separated/Divorced
Number of siblings: / Birth order:
Any current stress in the family?
e.g. death of family member, health issues, recent divorce or separation, change of schools, peer issues, etc
FIRE LIGHTING DETAILS
Date of most recent fire lighting incident:
Detailed description of most recent fire lighting incident (including a description of your child’s involvement in the fire lighting incident, the methods used and the extent of damage):
As a result of the fire lighting incident:
Fire brigade attended
Police attended
Ambulance attended
There was parental or adult intervention
Other (please specify):
Including the current fire lighting incident, how many times has your child played with fire, including matches or lighters, or set something on fire?
Please return the completed form to the JAFFA Coordinator:
Email:
Fax: 9395 9462
For more information phone: (08) 9395 9488

Version 5 | July 2015