Term 1, 2022 -Circle of Security Teens (ONLINE) Group Registration

Term 1, 2022 -Circle of Security -Teens Online Group Registration
NOTE: These programs are funded for the Northern Sydney region. Therefore participants will need to be living in the Northern Sydney region to participate (this includes online groups)
By filling out this form you are agreeing to commit to the full program should you be offered a spot.

Your spot in the group will be confirmed once you receive a reply confirmation email/sms from our team within the coming weeks. (By completing this form it does not mean you are automatically enrolled in the program)
Circle of Security Teen focus group Starts February the 23rd - March 30th (6 weeks) |

Wednesdays 10am-12pm
You must have a child 12 years or older in order to enrol into the program.
(you must attend the full program)

If you have any other questions please email us at intakefs@catholiccaredbb.org.au
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
What are the ages of your children?*
Do you identify as Aboriginal or Torres Strait Islander?*

YesNo
Do any of your children identify as Aboriginal or Torres Strait Islander?*

YesNo
Were you born in Australia or Overseas?*

AustraliaOverseas
If born overseas which country?*
Do you speak another language?*

YesNo
If you speak another language which language is it?*
Are you a sole parent?*

YesNo
Do you have a disability?*

YesNo
If you have a disability please describe;*
Do any of your children have a disability?*

YesNo
If your child/ren have a disability please describe;*
Have you ever been diagnosed with a mental health (MH) issue by a health professional? (The reason we ask for the above information is to ensure we are providing a safe environment for participants without triggering impacts on their mental health)*

YesNo
If yes to the previous question please describe;
To help us measure the outcomes of our programs please take the time to answer the following questions. These rating questions will be asked again at the completion of the program to measure any differences.

Rating scale is:

1. Negative impact (Significant negative impact)

2. Moderate negative impact (Moderate negative impact)

3. Middle ground (Progress towards improvments)

4. Adequate over the short terms (Things are going ok over short terms)

5. Adequate and stable over the medium term (Things are ongoingly adequate)

Please rate the following around you and your families circumstance:*

	1. Negative impact	2. Moderate negative impact	3. Middle ground	4. Adequate over short term	5. Adequate and stable over the medium term
Family functioning (eg, family relationships, family supports)

Please rate the following around you and your families goals:*

	1. No progress	2. Limited progress with emerging engagement	3. Limited progress with strong engagment	4. Moderate progress	5. Fully achieved
Knowledge and access to information (able to gain knowledge and info of what is needed to meet you and your families needs)
Able to change behaviours to improve independence, participation and wellbeing

How did you hear about the program?*
Do you consent to being contacts by CatholicCare for survey/research/evaluation purposes?*

YesNo
Do you consent to the following: I understand that as a funded organisation CatholicCare gathers pertinent information to meet its reporting requirements. I give consent for my details to be stored on the government Data Exchange (DEX). I hereby give CatholicCare permission to collect and collate relevant information about my family and me to be used for statistical reporting purposes.*

YesNo
Signature*

Clear
Thank you for taking the time to register for our parenting programs.

Please note these programs take time and effort to deliver and so we ask that if you register and are offered a spot in a program that you please commit to the program.
Should be Empty:

Term 1, 2022 -Circle of Security -Teens Online Group Registration

NOTE: These programs are funded for the Northern Sydney region. Therefore participants will need to be living in the Northern Sydney region to participate (this includes online groups)

By filling out this form you are agreeing to commit to the full program should you be offered a spot.