Juvenile and Family Fire Awareness Program

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:
Is an interpreter required? / Yes / ☐ / No / ☐ / Not known / ☐
If yes, language spoken?
Does your child have a learning/behavioural disorder? / Yes / ☐ / No / ☐ / Not known / ☐
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 / ☐
Other (please specify):
*Is your child medicated? / Yes / ☐ / No / ☐ / Not known / ☐
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?
Are you happy for the firefighter to visit your home to deliver the JAFFA education session? / Yes / ☐ / No / ☐

Please return the completed form to:

For more information phone: (08) 9395 9488

September 2016