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Home » For Service Providers » FASS Client Referral Form

Family Advocacy and Support Services Client Referral Form

"*" indicates required fields

____

Once you complete the form, an assessment will be conducted to see whether the client fits our criteria.

Please be aware referrals may take up to three weeks to action due to staff unavailability whilst Family Law Court is sitting.

Privacy Statement

Linking Communities Network Ltd collects your personal information in order to provide assistance, support and advocacy to clients. This information will provide important statistics and help us find the most suitable service to suit your needs. Your personal information is protected under law and will not be passed on to anyone without your consent

Question for client
Do you provide consent for your personal information (name, sex, date of birth and suburb), the date you applied for assistance and the name of this service; to be available to other government and non-government support services in NSW for one year after today’s date? Your personal information will be managed in accordance with the Information Privacy Act 2009.

Consent*

Yes, I provide consent

Referrer Details

Date*

Day

Month

Year

Referrer Name*

Referrer Phone Number*

Referrer Email Address*

Referrer Organisation*

Client Details

Family Name*

Given Name*

Alias

Date of Birth

DD slash MM slash YYYY

Gender

Female

LGBTQi+

Gender fluid

Disability

Yes

No

If yes, please specify disability

Anglo

Yes

No

Aboriginal/Torres Strait Islander

Yes

No

Multicultural

Yes

No

Is client on a temporary VISA?

Yes

No

If yes, what type of VISA?

Interpreter required?

Yes

No

Interpreter (Please specify)

Language

Country of Birth

Phone Contact

Phone Number*

Safe to call on this number?

Yes

No

If no, please give details of another number for contact or a preferred time to contact

Address

Street Address Address Line 2 City State Postcode

Email Address

Children

Number of children under 18 years in the care of the client

Child 1

Name

Date of Birth

DD slash MM slash YYYY

Child 2

Name

Date of Birth

DD slash MM slash YYYY

Child 3

Name

Date of Birth

DD slash MM slash YYYY

Child 4

Name

Date of Birth

DD slash MM slash YYYY

Child 5

Name

Date of Birth

DD slash MM slash YYYY

Other Party Details

Family Name

Given Name

Alias

Date of Birth

DD slash MM slash YYYY

Gender

Male

Female

Other

Address

Relationship of other party to the client*

Married

De Facto

Court Matter

Parenting

Financial

Both

Unknown

DFV History with other party?

Yes

No

Unknown

Child protection concerns disclosed?*

Yes

No

If yes, please list concerns

Are there any protection orders in place?

Yes

No

Unknown

Does the client have legal representation?

Yes

No

Unknown

If yes, who is the client’s lawyer?

Other Support Services or Programs involved with client

Do you have any further

Please upload any relevant forms or further information including AVO's, DVSAT, parenting plans, court orders etc.

Drop files here or

Max. file size: 64 MB.

Email

Contact

Phone (office only)

Please see individual programs
for phone numbers.

After Hours

Address (office)

177 Yambil St,
Griffith NSW 2680

Opening Hours

Monday, Tuesday, Thursday, Friday
9:00am - 5:00pm

Wednesday
1:00pm - 5:00pm

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