Request for multi-agency meeting

Date of referral:
Referral to information coordination meeting / Referral to SCAN team
ICM referrals must meet all the following criteria:
The child protection concerns have been reported to Department of Child Safety regional intake
The matter has been recorded as a child concern report (CCR)
Further discussion with regional intake team leader by SCAN team core member representative regarding decision and rationale has occurred
Name of officer:
Date of discussion:
The matter remains a CCR and multi-agency discussion is required. / SCAN team referrals must meet the following mandatory criteria:
The child protection concerns have been reported to Department of Child Safety regional intake
the matter has been assessed by Child Safety as meeting the threshold for recording a notification and/or
Child Safety is responsible for ongoing intervention with the child through a support service case, intervention with parental agreement or a child protection order and
coordination of multi-agency actions is required to effectively assess and respond to the protection needs of the child.
For reporting purposes, please indicate if any of the following conditions are relevant:
child has medical condition and parent/s not meeting health needs
child self-harming or suicidal
child homeless
child demonstrating inappropriate sexualised behaviour
substance abuse concerns - child and/or parent/s
mental health concerns - child and/or parent/s
concerns due to disability - child and/or parent/s
domestic and family violence
child protection concerns relate to an unborn child
a care and treatment order has been made by a designated medical officer.

Important notice about confidentiality: This document is intended only for the addressee and may contain confidential information. You are notified that any unauthorised transmission, distribution or photocopying is prohibited. The confidentiality attached to this facsimile is not waived, lost or destroyed by reasons of a mistaken delivery to you. If you have received this facsimile in error please notify us immediately by telephone.

Family Name: Jun 2010 3

Request for multi-agency meeting

Children referred
Family name (include alias): / Given names: / Date of birth: / Child’s address: / Sex: / Referring agency’s client ref. no:
~MaleFemaleUnknown
CALD: / School or CCC: / Doctor: / OHC placement: / Primary harm:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~YesNoUnknown / ~Physical harmAt risk physicalSexual harmAt risk sexualEmotional harmAt risk emotionalNeglectAt risk neglect
Family name (include alias): / Given names: / Date of birth: / Child’s address: / Sex: / Referring agency’s client ref. no:
~MaleFemaleUnknown
CALD: / School or CCC: / Doctor: / OHC placement: / Primary harm:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~YesNoUnknown / ~Physical harmAt risk physicalSexual harmAt risk sexualEmotional harmAt risk emotionalNeglectAt risk neglect
Family name (include alias): / Given names: / Date of birth: / Child’s address: / Sex: / Referring agency’s client ref. no:
~MaleFemaleUnknown
CALD: / School or CCC: / Doctor: / OHC placement: / Primary harm:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~YesNoUnknown / ~Physical harmAt risk physicalSexual harmAt risk sexualEmotional harmAt risk emotionalNeglectAt risk neglect
Family name (include alias): / Given names: / Date of birth: / Child’s address: / Sex: / Referring agency’s client ref. no:
~MaleFemaleUnknown
CALD: / School or CCC: / Doctor: / OHC placement: / Primary harm:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~YesNoUnknown / ~Physical harmAt risk physicalSexual harmAt risk sexualEmotional harmAt risk emotionalNeglectAt risk neglect
Family name (include alias): / Given names: / Date of birth: / Child’s address: / Sex: / Referring agency’s client ref. no:
~MaleFemaleUnknown
CALD: / School or CCC: / Doctor: / OHC placement: / Primary harm:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~YesNoUnknown / ~Physical harmAt risk physicalSexual harmAt risk sexualEmotional harmAt risk emotionalNeglectAt risk neglect
Family name (include alias): / Given names: / Date of birth: / Child’s address: / Sex: / Referring agency’s client ref. no:
~MaleFemaleUnknown
CALD: / School or CCC: / Doctor: / OHC placement: / Primary harm:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~YesNoUnknown / ~Physical harmAt risk physicalSexual harmAt risk sexualEmotional harmAt risk emotionalNeglectAt risk neglect
Relationships (Both within child’s primary residence and outside primary residence)
Family name (include alias): / Given names: / Date of birth: / Home address: / Referring agency’s client ref. no: / Sex: / CALD: / Relationship to child:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
Alleged person responsible
Family name (include alias): / Given names: / Date of birth: / Home address: / Referring agency’s client ref. no: / Sex: / CALD: / Relationship to child:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown / ~FatherMotherStep-fatherStep-motherSiblingGrandfatherGrandmotherAuntUncleOther relativeFriendApproved carerOther relationship

Family Name: Jun 2010 3

Request for multi-agency meeting

Relevant police and child protection history – by individual
Family name (include alias): / Given names: / Date of birth: / Referring agency’s client ref. no: / Sex: / CALD:
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown
~Aboriginal and Torres Strait IslanderAfricanAnglo-AustralianAsianAustralian AboriginalAustralian South Sea IslanderAustralian Torres Strait IslanderCentral American (Country Unknown)ChineseEuropeanMaoriMiddle EasternNorth American (Country Unknown)Pacific IslanderPapuanSomaliSamoanSouth American (Country Unknown)SudaneseTonganVietnameseOtherUnknown
Relevant information:
Other relevant information

Family Name: Jun 2010 3

Request for multi-agency meeting

Rationale for ICM referral
Summary of child protection concerns and actions undertaken (including identified risk factors and protective needs for the child):
Rationale for SCAN team referral
Summary of child protection concerns and actions undertaken (including identified risk factors and protective needs for the child):
Other agencies / stakeholders able to contribute to addressing the identified risks and protective needs for the child. Please provide advice to SCAN team coordinator of other stakeholders to be invited 3 business days prior to the scheduled case discussion unless otherwise negotiated.
Individuals to be informed of SCAN team referral
Name of those informed:
Reason if not informed:
Referring officer and agency: / Date: / Supervisor: / Date: / Approving core member representative: / Date:
Signature of core member representative:

Family Name: Jun 2010 3