42 Jubilee Avenue, Carlton, NSW 2218
02 9553 9100
02 9553 8711
St George Family Support Service Inc.

Service Referral Form

The office phones are manned between 9:30am & 3:00pm. Monday-Friday

    All fields are mandatory where applicable

    Method of Referral

    PhoneFaxFace to faceEmailWebsite

    Referred by

    AgencySelf




    Authorisation and Consent

    Please note: Unless the guardian consent section has been given and all sections are completed, we are unable to accept this referral.

    I understand and agree for St. George family support services to receive my personal details. I understand my involvement is voluntary and I may withdraw from the service at any time. I give consent for the referrer to share information relating to my family support needs.



    Family Details

    Primary Carer 1

    Covid-19 vaccinated (help is still available if you are unvaccinated):

    YesNo





    Preferred contact:

    Home PhoneMobileEmail

    Leave message:

    YesNo

    Primary Carer 2

    Covid-19 vaccinated (help is still available if you are unvaccinated):

    YesNo





    Preferred contact:

    Home PhoneMobileEmail

    Leave message:

    YesNo

    Children's Details:






















    Please Select Appropriate Boxes

    Residential status

    Australian citizenPermanent residentNon-resident

    Visa type (only if non-resident):

    Are community services involved

    Community services involved:

    YesNo

    Days available:

    MondayTuesdayWednesdayThursdayFriday

    Current Family Situation

    Please select all that apply:

    Living

    HNSW/CommunityWith familyPrivate rentalHomelessOwn homeCouch surfingCrisis accommodationShare accommodationOther


    Child(ren)

    Mental healthLearning disabilityHealth issuesBehavioral issuesSelf harming/otherDevelopmental issuesSchool concernsDisabilityOther


    Domestic violence

    DV identified:

    YesNo

    PhysicalVerbalSexualFinancialEmotional/psychologicalSocialSpiritualChildren WitnessLegalAvo/breachesPrevious relationship

    Parent/Carer

    Details:

    Child/Ren at riskDrug/alcoholHousing issuesMental health/anxietyDisabilityFinancial/gambling

    Income details:

    CentrelinkEmploymentImmigrationOther


    Details Background Information Including Perceived Risks

    Expected Outcomes

    Safety

    Is client safe?

    YesNo

    Is there an AVO?

    YesNo

    Drug/alcohol

    YesNo

    Mental health

    YesNo

    Safety plan details:

    Other Services Involved













    Emergency Contact Details:



    Interpreter required?

    YesNo

    Or alternatively print out form: Client Intake Referral Form