Family Practitioner Request for Staff Form
Updated 31.10.2024
Request date/time - no need to fill out this section it's automatic
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Date
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Minutes
AM
PM
AM/PM Option
Referring Agency
*
Contact Person Name
*
Contact Person Email Address
*
Contact Person For Billing Purposes
*
Accounts Email Address
*
Has the request been fully approved by the Department?
*
Yes
No
Do you require a quote for this request?
*
Yes
No
Requirements of Worker
*
Category 2 (Experienced)
Category 3 (Very Experienced)
Category 4 (Professional Level)
Qualification Requirements of Worker
*
Certification IV Child, Youth of Family Intervention or relevant certificate
Diploma Child, Youth of Family Intervention or relevant certificate
Bachelor of Social Work, Social Science, Psychology or similar
Is COVID 19 Vaccination required for the staff providing support?
*
Yes
No
Provide the home address the ProCare Australia Worker will be attending
Street Address
Street Address Line 2
City
State
Postcode
Date and Time of Shift/s- *The Request will not be actioned without Dates and Start Time and Finish Time entered
*
Has the Family Agreed to the above Dates and Times of shifts? *The Request will not be actioned if the Family are not in agreeance
*
Yes
No
Has a Home Visit Risk Assessment been completed? *The Request will not be actioned if the Home Visit Risk Assessment has not been completed
*
Yes
No
Job Brief
*
What is to be achieved by the ProCare Au staff member?
Does the assigned ProCare Australia worker require an NDIS Check Clearance to complete the shift requested?
*
Yes
No
Approved Attendee/s (if required)
*
Name One
Name Two
Name Three
Name Four
Attendee/s Name
Relationship Status (parent/participant/family member/care provider/client)
Participant/Clients Information
Are Case Notes required to be completed on shift?
*
Not Required
15 Minutes
30 Minutes
Case Notes
Child Safety Seat- if required
*
Forward Facing Infant
Booster Seat
Rear Facing Infant
Not Required
Known Safety Concerns or Risk Factors that may impact the requirements of the shift
*
Pre-Approved Allowances (if required)
*
Authorisation of shift Approval (contact for time sheets approval)
Name
Email
Position
Contact Number
Approver
Submit
Should be Empty: