Togetherness

Keeping Children Connected while Supporting Families in Transition

APPLICATION FOR SUPERVISION

An Application form must be returned and the Intake Assessment completed prior to commencement of Family Supervision and/or Changeovers Applicants Details
Name of Applicant Address Home Phone Number E-mail Address Relationship to child/ren Ethnic Background Language spoken Do you have a disability? Yes No Do you require an interpreter? If Yes, please state disability Yes No Mobile Number

Your Income Details

Are you currently employed? Employers Name Employers Address Work Phone Number Source of Income if not employed Do Court Orders specify that costs for Family Supervision are to be shared between the parents? If not, who is the fee paying parent? Yes No Work E-mail Address Yes (provide details below) No (go to source of income)

Your Legal Representation

Solicitors Name Solicitors Firm

Togetherness Keeping Children Connected while Supporting Families in Transition PO Box 1319 Bundoora Vic 3083 Telephone: 0497 840 124 Fax: 1900 970 270 Email: togetherness@hotmail.com.au 1

Togetherness
Keeping Children Connected while Supporting Families in Transition

APPLICATION FOR SUPERVISION

Solicitors Address Solicitors Phone Number Solicitors E-mail Address Solicitors Fax Number

Infectious Medical Condition (full disclosure is required for OH&S purposes)

Do you have any chronic infections or medical conditions that may put the child or supervisor at risk eg: H.I.V., Hepatitis? Yes No

If Yes then the food/drink etc must be provided by the resident parent, unless there is a letter from the contact parents medical practitioner, advising that the person with the condition does not pose a health threat to the child and to the supervisor.

Signed

Date of Signature

Ex-Partners Information
Name of the Other Parent Their Address Details Phone Number E-mail Address Relationship to child/ren Ethnic Background Language spoken Do they have a disability? Yes No Do they require an interpreter? If Yes, please state disability Yes No Mobile Number

Ex-Partners Legal Representation

Solicitors Name Solicitors Firm Solicitors Address Solicitors Phone Number Solicitors E-mail Address Solicitors Fax Number

Togetherness Keeping Children Connected while Supporting Families in Transition PO Box 1319 Bundoora Vic 3083 Telephone: 0497 840 124 Fax: 1900 970 270 Email: togetherness@hotmail.com.au 2

Togetherness
Keeping Children Connected while Supporting Families in Transition

APPLICATION FOR SUPERVISION

Department of Human Service Child Protection Involvement (full disclosure would be appreciated)
Has DHS has an involvement with any of the Parents/Partners/Children? Child Protection Workers Name Office of Child Protection Worker Address of Office Office Phone Number Workers E-mail Address Office Fax Number Yes (provide details below) No

Intervention Orders (full disclosure would be appreciated)

Are there any current Intervention Orders involving the Parents/Partners/Children? If yes, when is the next Court Return Date? Please provide brief details and attach a copy of the Intervention Orders. Yes (provide details below) No

Child/rens Information
Please Note: If there are more than three (3) children then arrangements must be made for a second supervisor. This rule and regulation is outlined in the HANs Client Handbook. Name of Child 1 Date of Birth of Child Childs residential address Any medical conditions, dietary requirements, allergies or special needs? Please specify Name of Child 2 Date of Birth of Child Childs residential address Any medical conditions, dietary requirements, Age of Child Country of Birth Age of Child Country of Birth

Togetherness Keeping Children Connected while Supporting Families in Transition PO Box 1319 Bundoora Vic 3083 Telephone: 0497 840 124 Fax: 1900 970 270 Email: togetherness@hotmail.com.au 3

Togetherness
Keeping Children Connected while Supporting Families in Transition

APPLICATION FOR SUPERVISION

allergies or special needs? Please specify Name of Child 3 Date of Birth of Child Any medical conditions, dietary requirements, allergies or special needs? Please specify Name of Child 4 Date of Birth of Child Childs residential address Any medical conditions, dietary requirements, allergies or special needs? Please specify Age of Child Country of Birth Age of Child Country of Birth

DEPOSIT IS PAYABLE IN ADVANCE FOR SERVICE DELIVERY I, __________________________________________ (please print your name) agree to pay a deposit into Togetherness business bank account (or some other method of payment stipulated by the agency) two (2) days prior to the first day of contact an amount that is equal to the cost of the Intake Process ($330) and the first week of supervision, including the cost of the observation notes plus the cost of the kilometers chargers for transportation of the child/ren. I agree that: the first supervised session may be postponed if this deposit is not paid; observation notes ($35 each session) are compiled to form a Court Report ($500) and will not be available for either party/or lawyers unless the account is paid in full; the deposit will be off-set against the last invoice issued in effect rendering the last invoice as paid; cancellation must be notified more than 24 hours prior to the contact taking place; notification of cancellation 24 hours or less may incur a later cancellation fee of 2 hours relevant to the day of contact; cancellation of a Supervision session that has not been notified by either parent and where the Supervisor attends the arranged pick-up point will incur a late cancellation of 2 hours, relevant to the day of contact; NOTE THAT: if the parent (who has not been deemed responsible for payment outlined in the Family Court Order) cancels access less than 24 hours out from the time of access then that parent is responsible for the payment of the late cancellation fee;

Togetherness Keeping Children Connected while Supporting Families in Transition PO Box 1319 Bundoora Vic 3083 Telephone: 0497 840 124 Fax: 1900 970 270 Email: togetherness@hotmail.com.au 4

Togetherness
Keeping Children Connected while Supporting Families in Transition

APPLICATION FOR SUPERVISION

If the child/ren are not released for time with the non-residential parent, then a medical certificate outlining the reason for non-attendance is required; I agree to send confirmation of payment by SMS on 0400 770 914 or to togetherness@hotmail.com.au the Supervisor is contracted to provide supervision for the number of hours recorded on the court order unless changes have been notified to the Managing Director more than 24 hours prior to the time of the scheduled session; I am responsible for cost relating to the provision of interpreting services (if any); Togetherness is legally required to meet the conditions and stipulations recorded in the court orders; I agree to provide a copy of Court Orders that specify time arrangements between myself and the child/ren, along with any current Intervention Orders.

Please forward payment to: Togetherness Commonwealth Bank BSB 06 3234 Account: 1081 7351 Please tag direct deposit with your surname Alternatively, payment by Eftpos is also available.

Signature of client

Date of Signature

DEBT COLLECTION I, __________________________________________ (please print your name) agree to pay all invoices issued by Togetherness prior to service provision and acknowledge that if an invoice remains unpaid after seven (7) days, the following access session may be cancelled. I acknowledge that if the account is overdue, Togetherness at its discretion, reserves the right to refer the account to a Debit Collection Agency for Collection and I agree to be responsible to meet all reasonable costs and Commissions incurred in employing the said collection agent to collect the overdue account.
Signature of client Date of Signature

Togetherness Keeping Children Connected while Supporting Families in Transition PO Box 1319 Bundoora Vic 3083 Telephone: 0497 840 124 Fax: 1900 970 270 Email: togetherness@hotmail.com.au 5