Family Supervision Referral Form

Family Supervision Referral Form

Please complete this form and forward it to the other party/parent through your appropriate communication channel (i.e. via legal representatives or other means) for their agreement and signature.

Once the parties have reached an agreement, the COMPLETED Referral Form and Service Agreement documents plusa copy of the payment receipt for the Intake fee ($75) should be forwarded to the PRFC office by one of the parties. If you make amendments to the information on this form completed by the other party, please return to the other party for agreement to those changes PRIOR to sending to PRFC.

We will not accept referrals that are not signed by both parties nor will we accept referrals whereby the parties do NOT agree on the arrangement.

The completed form can be sent as an email attachmentalong with receipt for intake payment by mail or fax:

Email:

Mail: PO Box 71, Oatlands NSW 2117

Fax:02 9875 2123

This form is the sole document we will refer to for your contact supervision arrangements, including agreed venues and attendees.

If there is a change to the arrangement, you will need to complete a new Referral Form as per the instructions above.

PRFC is not able to negotiate between the parties. Therefore ALL negotiations must be completed by the parties, and this may involve their legal representation.

Contact Supervision Details
Family Name of child/ren
Child/ren Names *Please attach additional page if more than 5 children / Gender: M/F / D.O.B / Care needs: i.e. Food allergies, medical info
1.
2.
3.
4.
5.
6.
Attendees
Please list all people APPROVED to be present at each visit.
**Those persons not listed will be asked to leave the visit unless approval has been sought in advance of the service date. / Name / Relationship
Handover / Transport
Will the child/ren require transport by Phoenix Rising to and from the venue? / Yes (if yes, please ensure you have provided the pick-up and return location address, this information will remain confidential).
No
Will both parents be present at handover of the child/ren prior to the service start time? / Yes
No (If no, please provide further detail as below, requested meeting points for each person need to be identified).
If parents do not wish to come into contact, please specify a meeting point where the child/ren will be delivered to the supervisor, and a meeting point where the supervisor will meet the parent to be supervised. / Carer Parent meeting point:
Supervised Parent meeting point:
Car seating requirements for your child/ren?
If your child/ren require transport to and from the venue please specify the type of car seats required. / Baby reversible
Booster 1-4 years
Booster 4-7 years
Additional information
Please provide any specific information you feel would assist the supervisor on the day, this includes details about your child’s behaviour or interests.
Session Times
PRFC offer morning and afternoon session times for requeststhat are 5 hours in duration and under. These sessions times are as follows:
Morning session: 7.30am – 12.30pm
Afternoon session: 1.30pm – 8.30pm
When booking a visit please nominate the session time the visit will fall into and provide the actual hours you will require our service e.g.; Morning: 9-12pm or Afternoon: 2-6pm.
If the visit exceeds 5 hours, please nominate the time you prefer and PRFC will confirm if we have the availability to provide this requested time. If your requested time is not available, we will do our best to offer an alternative.
Supervised Family Contact - Proposed schedule:
Please ensure all fields are completed and mark NA if not required.
Pickup/handover - time the child/ren are collected from the carer parent.
Visit supervised time – time child/ren are face to face with supervised parent
Return/handover time – time the child/renare due to be returned to the carer
Venue name & address – provide as much detail as possible about the venue location
Date / Pickup / handover time / Visit - supervised time / Return/ handover time / Venue name & address
**If a venue is not on this form, we may not consider it for future visits. Please see attached ‘venue information’
Wet weather additional venue information:
Please nominate a wet weather venue if other venues requested are exposed to the weather eg; Parks and playgrounds. We will use this venue on occasion when the nominated one is not suitable.

Contact Supervision Agreement

I agree that the information provided in this form is correct and any changes/ additional dates will need to be approved by both parties and sent in writing to PRFC.

I agree that changes to this Referral Form without prior approval from the other party will incur an administration fee, invoiced to the person responsible for attempted changes.

Signed by:

Parent 2/ Person being supervised:

Print Name:
Signature:
Date:

Parent 1/ Person with whom child/ren resides:

Print Name:
Signature:
Date:

THIS FORM IS NOT VALID UNLESS THERE ARE 2 SIGNATURES AND BOTH PARTIES AGREE TO THE SCHEDULED ARRANGEMENTS.

Contact Venue Information

Phoenix Rising For Children's Family Contact Services use safe, neutral and child-focussed venues for supervised visits to occur between children and their parents.

Venues play an important role in the provision of this service. Whilst we are able to supervise visitation in the community, family homes and other natural settings, we need to ensure the venue is suitable for the purpose of supervision and supports the supervisor in providing a safe and controlled visit, maintaining the safety and well-being of children we are working with is our primary focus.

Venues can include:

- Libraries

- Parks

- Playgrounds

- Play centres

- Private residences (conditions apply)

- Entertainment venues

- Zoo’s and wildlife parks

- Aquariums

- Movies

- Bowling

- Shopping centres

- Restaurants

- Art Galleries

Some venues are considered high risk or do not allow the supervisor to perform their role, these include but are not limited to:

- Beaches, open bodies of water

- Ice or roller skating, rollerblading, skateboarding

- Laser tag

- Trampolining

- Rock climbing/ abseiling activities

- Horse riding

- Bike riding (may be considered at bike riding venues with the appropriate safety equipment)

- Swimming Centres/ Pools(may be considered if all parties agree, however the supervisor will not enter the water)

When completing your referral form, please note, venues must be included, we do not accept ‘to be advised’ locations. If you have a list of agreed venues, please choose a default venue, which will allow us to schedule your request. This default venue may change to another agreed venue, however, we require 7 days-notice of such changes.

We recommend that you speak with our team if you are considering different venues, to ensure they are appropriate and meet our requirements. This is especially important if you are currently in court and negotiating venues between yourself and the other party. It can be disappointing if you have agreed on a venue and our service is not able to facilitate contact at that location.

Please contact our Team for further information or if you have any questions regarding venues.

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