Supervised Contact Application Form

1
Applicant Details* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Day
Month
Year
3
Sex/Gender* This field is required.
Male
Female
Other
4
Home Address* This field is required.
Street Address
Street Address Line 2
Suburb
State
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Mobile Phone Number* This field is required.
6
Email Address* This field is required.
example@example.com
7
Indigenous Status* This field is required.
Please Select
Please Select
Aboriginal
Torres Trait Islander
Aboriginal & Torres Strait Islander
Neither
8
Nationality* This field is required.
9
Main Language Spoken* This field is required.
10
Relationship to Child/Children* This field is required.
Please Select
Please Select
Mother
Father
Grandmother
Grandfather
Carer/Other
11
How many Children is this Application For?* This field is required.
Just One
Two
Three
Four
Five
Six
12
Child 1 - Details* This field is required.
First Name
Last Name
13
Child 1 - Date of Birth* This field is required.
Day
Month
Year
14
Child 1 - Sex/Gender* This field is required.
Male
Female
Other
15
Child 1 - Nationality* This field is required.
16
Child 1 - Indigenous Status* This field is required.
Please Select
Please Select
Aboriginal
Torres Trait Islander
Aboriginal & Torres Strait Islander
Neither
17
Child 1 - Does Your Child Have Any Disabilities or Additional Needs?* This field is required.
YESNO
18
Child 1 - Details of Disabilities or Additional Needs
19
Child 2 - Details* This field is required.
First Name
Last Name
20
Child 2 - Date of Birth* This field is required.
Day
Month
Year
21
Child 2 - Sex/Gender* This field is required.
Male
Female
Other
22
Child 2 - Nationality* This field is required.
23
Child 2 - Indigenous Status* This field is required.
Please Select
Please Select
Aboriginal
Torres Trait Islander
Aboriginal & Torres Strait Islander
Neither
24
Child 2 - Does Your Child Have Any Disabilities or Additional Needs?* This field is required.
YESNO
25
Child 2 - Details of Disabilities or Additional Needs
26
Child 3 - Details* This field is required.
First Name
Last Name
27
Child 3 - Date of Birth* This field is required.
Day
Month
Year
28
Child 3 - Sex/Gender* This field is required.
Male
Female
Other
29
Child 3 - Nationality* This field is required.
30
Child 3 - Indigenous Status* This field is required.
Please Select
Please Select
Aboriginal
Torres Trait Islander
Aboriginal & Torres Strait Islander
Neither
31
Child 3 - Does Your Child Have Any Disabilities or Additional Needs?* This field is required.
YESNO
32
Child 3 - Details of Disabilities or Additional Needs* This field is required.
33
Child 4 - Details* This field is required.
First Name
Last Name
34
Child 4 - Date of Birth* This field is required.
Day
Month
Year
35
Child 4 - Sex/Gender* This field is required.
Male
Female
Other
36
Child 4 - Nationality* This field is required.
37
Child 4 - Indigenous Status* This field is required.
Please Select
Please Select
Aboriginal
Torres Trait Islander
Aboriginal & Torres Strait Islander
Neither
38
Child 4 - Does Your Child Have Any Disabilities or Additional Needs?* This field is required.
YESNO
39
Child 4 - Details of Disabilities or Additional Needs* This field is required.
40
Child 5 - Details* This field is required.
First Name
Last Name
41
Child 5 - Date of Birth* This field is required.
Day
Month
Year
42
Child 5 - Sex/Gender* This field is required.
Male
Female
Other
43
Child 5 - Nationality* This field is required.
44
Child 5 - Indigenous Status* This field is required.
Please Select
Please Select
Aboriginal
Torres Trait Islander
Aboriginal & Torres Strait Islander
Neither
45
Child 5 - Does Your Child Have Any Disabilities or Additional Needs?* This field is required.
YESNO
46
Child 5 - Details of Disabilities or Additional Needs* This field is required.
47
Child 6 - Details* This field is required.
First Name
Last Name
48
Child 6 - Date of Birth* This field is required.
Day
Month
Year
49
Child 6 - Sex/Gender* This field is required.
Male
Female
Other
50
Child 6 - Nationality* This field is required.
51
Child 6 - Indigenous Status* This field is required.
Please Select
Please Select
Aboriginal
Torres Trait Islander
Aboriginal & Torres Strait Islander
Neither
52
Child 6 - Does Your Child Have Any Disabilities or Additional Needs?* This field is required.
YESNO
53
Child 6 - Details of Disabilities or Additional Needs* This field is required.
YESNO
54
Who Does Your Child/Children Currently Live With?* This field is required.
Please Select
Please Select
Mother
Father
Grandparent(s)
Carer/Other
55
Do You Have a Parenting Plan, Parenting Agreement or Court Orders?* This field is required. NOTE: If Yes, a copy will be required.
YESNO
56
Are there any current AVO's in Place?* This field is required. NOTE: If Yes, a copy will be required.
YESNO
57
Is there an Open Case with DCJ for Your Child/Children?* This field is required.
YESNO
58
Name of DCJ Caseworker
59
Contact Number for DCJ Caseworker
Please enter a valid phone number.
60
Do You Have a Solicitor/Lawyer/Barrister?* This field is required.
YESNO
61
Name of Your Solicitor/Lawyer/Barrister* This field is required.
62
Contact Phone Number for Your Solicitor/Lawyer/Barrister* This field is required.
63
Does Your Child/Children have an Independent Children's Lawyer?* This field is required.
YESNO
64
Name of Your Child/Children's Independent Children's Lawyer* This field is required.
65
Contact Phone Number for Independent Children's Lawyer* This field is required.
66
Have You Used a Supervised Children's Contact Service Previously?* This field is required.
YESNO
67
Name of Children's Supervised Contact Service Previously Used* This field is required.
68
Reason for Ceasing Use of Previous Children's Supervised Contact Service* This field is required.
Huge
Large
Normal
Small
Ok
Ok
69
Requested Frequency of Supervised Contact Visits* This field is required.
Once per Week
Twice per Week
Three Times per Week or More
Fortnightly
Monthly
Every 2 Months
Four Times per Year
Three Times per Year
Twice per Year
Once per Year
Once Off Visit Only
Full Weekend Supervision
Full Week Supervision
Holiday/Vacation Supervision
70
Requested Days for Supervised Contact Visits to Occur* This field is required.
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Sundays
71
Requested Start Time for Supervised Contact Visits
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
Until
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
PM
AM
PM
72
Details of Other Parent/Visiting Family Member* This field is required.
First Name
Last Name
73
Relationship of Other Parent/Visiting Member to Child/Children* This field is required.
Please Select
Please Select
Mother
Father
Paternal Grandparent
Maternal Grandparent
Paternal Uncle
Maternal Uncle
Paternal Aunty
Maternal Aunty
Other
74
Sex/Gender of Other Parent/Visiting Family Member* This field is required.
Male
Female
Other
75
Address of Other Parent/Visiting Family Member (if known)
Street Address
Street Address Line 2
Suburb
State
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
76
Contact Number for Other Parent/Visiting Family Member (if known)
77
Email Address for Other Parent/Visiting Family Member (if known)
example@example.com
78
Indigenous Status of Other Parent/Visiting Family Member
Please Select
Please Select
Aboriginal
Torres Strait Islander
Aboriginal & Torres Strait Islander
Neither
Don't Know
79
Nationality of Other Parent/Visiting Family Member
80
Main Language Spoken by Other Parent/Visiting Family Member* This field is required.
81
Does the Other Parent/Visiting Family Member Know You Are Applying for Supervised Contact with Hope Family Cottage?* This field is required.
YESNO
82
Who Will Be Responsible for Paying Our Fees & Other Costs for Visits?* This field is required.
Please Select
Please Select
Me
Other Parent
Both of Us
Solicitor/Lawyer?Barrister via JustFund
Grandparent/Carer
Other
83
Upload a Copy of your Drivers' Licence Here (Front & Back)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
84
Upload a Copy of Your Passport Photo ID Here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
85
Upload a Copy of any Current AVO's Here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
86
Upload Any Parenting Agreement/Plan and/or Court Orders Here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
87
Declaration: I hereby declare and understand that:
All information I have provided is accurate and true to the best of my knowledge;
Hope Family Cottage may contact any Children's Supervised Contact Service previously used to assist with my Application;
The use of any violent, aggressive or coercive/controlling behaviour will not be tolerated under any circumstances, and any such behaviour will result in the immediate termination of all services provided by Hope Family Cottage;
No services will be provided by Hope Family Cottage without payment being made in full prior;
Hope Family Cottage does not decide, or get involved in, discussions with Parents/Family Members or any Other Parties regarding who is responsible for the payment of Our Fees and/or Other Costs;
Hope Family Cottage Reserves the Right to Refuse an Application at their sole discretion without providing any explanation as to why.
88
Signature* This field is required.
Should be Empty: