Supervised Contact

Supervised Contact

Intake Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Children

MotherFatherOther
If other please specify
Source of Income

EmployedNot employedOther
If other please specify
Ethnic Background / Language
Ethnicity:
Language:
Interpreter Required

YesNo
Do you speak English

YesNo
Do you have a Disability?

YesNo
If yes, a description is required:
Legal Representation
Name of Solicitor & His or Her Firm
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Spouse / Partner's Information
Name of previous partner

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to child/children

MotherFatherOther
Other Relationship (explain as briefly as possible)
Ethnicity:
Language:
Is an interpreter required

YesNo
Do they speak English

YesNo
Do they have a Disability

YesNo
If yes, a description is required:
Legal Representation - Name of Solicitor & His or Her Firm & a contact number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has DHS had involvement with any of the Parent's Children. If yes, explain in full.
Child Protection workers Name & Contact Number
Child Protection Workers Email
example@example.com
Signature

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Date

MonthDayYear
Date
l blanks agree that I will pay all costs into Child and Adolescent Psychology Services Pty Ltd bank account at least 48 hours prior to first contact or other services commencing, an amount that is equal to the cost for the first fortnight of supervised contact and any other services provided
Signature

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Date

MonthDayYear
Date
Please make payment to:

Child and Adolescent Psychology Services Pty Ltd

BSB: 083 310

Acc: 12 119 7946

Please put your last name on the deposit.

The first scheduled day of supervised contact may be postponed if the cost is not
paid in advance;
• Observation notes will not be made available for either party or their legal represenation during an ongoing period of visits. Additional information can be provided regading the costs associated with supboenas, affadavits and court reports upon request.
• Notification of cancellation of supervised contact 24 hours or less will incur a late
cancellation fee of 2-hours relevant to the day of contact if no medical certificate
is provided advising the child is unwell. If no doctor’s certificate is produced two
hours’ cancellation fee will be charged to the residential parent.

CAPS staffer will facilitate a family contact visit which is monitored and controlled in a safe controlled environment. CAPS are a private organisation and do not receive government funding. Families accessing this service are required to fund the full cost of services accessed, payable in advance.

Weekdays $110 (inc gst) per hour

Weekends $140 (inc gst) per hour

Public Holidays $160 (inc gst) per hour
Child/ren's Information
Number of Children to be supervised for contact:
First Child's Name

First NameLast Name
Date of Birth
Gender

MaleFemaleOther
Age
Country of Birth
Does this Child speak English?

YesNo
If no, what language?
Is an interpreter required

YesNo
Parenting Arrangements
Residence (who the child lives with )
Contact (who the child has contact with)
How long since the child has seen or spoken to the contact parent?
Child's Medical Information
Is there a medical prescription for medicine that the child may have to take while on supervised contact:

YesNo
If yes, name the medication:
Time for the medication to be taken:
What arrangements have been made for the supervised parent to administer this medication
Please note that the supervisor cannot be responsible for administering medicine.

Medication administration arrangements must be made between the parents before

contact occurs and needs to be in writing from a solicitor of either parent to FCS.
Parenting Order - are the arrangement's listed in a Parenting/Family Court Order:

YesNo
If yes, select which is relevant:

Family CourtMagistrates CourtChildren's Court
Second Child's Details
Name

First NameLast Name
Date of Birth
Age
Gender

FemaleMaleOther
Country of Birth
Does this child speak english

YesNo
If no, what language
Is an interpreter required

YesNo
Parenting Arrangements
Residence (who the child lives with)
Contact (who the child has contact with)
How long since the child has seen or spoken to the contact parent?
Second Child's Medical Information
Is there a medical prescription for medication that the child may have to take while on supervised contact:

YesNo
If yes, name the Medication
Time for Medication to be taken:
What arrangements have been made for the supervised parent to administer this Medication
Please note that the supervisor cannot be responsible for administering medication.

Medication administration arrangements must be made between the parents before

contact occurs and needs to be in writing from a solicitor of either parent to FCS.
Parenting Order - are the arrangements listed in a Parenting / Family Court Order?

YesNo
If yes, select which is relevant

Family CourtMagistrates CourtChildren's Court
If there are more than two children to be involved in contact - please contact CAPS via sienna@childandadolescentpsych.com.au for more forms.
Service Required
Contact Visit Changeover

YesNo
Supervised Access Visit

YesNo
Please provide copies of current court orders including IVO's and advise when first service is to start and when the next court date/s are to sienna@childandadolescentpsych.com.au
Have you used any other Supervision Agency

YesNo
If yes, please provide the following details, name of the Agency:
Agency Contact Number
Please enter a valid phone number.
Please provide a brief reason for changing Agencies

Current and Historical Concerns*

	YES	NO	NOT KNOWN
Harassment of Family Members or others
STALKING
SUBSTANCE ABUSE (ALCOHOL / DRUGS)
POSSESSION OF FIREARMS
ASSAULT OF FAMILY MEMBERS
CRIMINAL CHARGES/ CONVICTIONS
INTERVENTION ORDERS CURRENT
BREACHED COURT ORDERS

If you have answered yes to any of the above, please provide further details. This would include type of incident, date and persons involved. If any Police action occurred and if the child/ren exposed to this incident.
PLEASE NOTE THAT ALL THE INFORMATION PROVIDED BY YOU IS NOT SHARED WITH ANYONE ELSE OTHER THAN EMPLOYEE’S OF CAPS CONTACT SERVICE.
Should be Empty:

Supervised Contact

Ethnic Background / Language

Legal Representation

Spouse / Partner's Information

Child/ren's Information

Parenting Arrangements

Child's Medical Information

Second Child's Details

Parenting Arrangements

Second Child's Medical Information

Service Required