Intake Form

1

Full Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

3

Email Address* This field is required.

example@example.com

4

Phone Number* This field is required.

Please enter a valid phone number.

5

Why are you seeking supervised contact?* This field is required.

Court Orders

Other

6

I have read The Good Shepherd ccs's Privacy Policy* This field is required.Must Read before proceeding

YES

7

I have notified the other party/other party's legal representative, and the above dates are suitable.* This field is required.

YES

8

Relationship to the child/children:* This field is required.

Mother

Father

Other

9

If "Other", type in your relationship to the child/children* This field is required.

10

How long do you need supervised contacts for?* This field is required.

11

Where does the child/children spend most of their time?* This field is required.

12

How many days do you see the child?* This field is required.

13

Type of service required:* This field is required.

Supervised ContactChild

Supervised Changeover

Supervised Transport

Familiarisation Session

Meet and Greet

14

Approx Commencement Date* This field is required.

Date

15

Current Parenting arrangement in place* This field is required.

Informal Parenting Plan

Interim Order

Consent Order

Final Order

16

Upload a copy of the Document ticked above* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

17

Please tick any of the below apply* This field is required.

Police Charges or AVO's - current and within the last two years

Psychiatric or Psychological Reports

Family Reports

18

Upload a copy of the Document ticked above* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

19

Child/rens Names* This field is required.

20

Health concerns/allergies* This field is required.

21

Disability or mental health concerns* This field is required.

22

Main Language Spoken (Is an interrupter needed?)* This field is required.

23

Other Notes

24

Name * This field is required.

25

Relationship To Child* This field is required.

26

Address* This field is required.

27

Phone (M)* This field is required.

28

Location of contact visit (Must Include The Suburb)* This field is required.Suitable sites McDonalds Parks Libraries Movie theatres Zoos and aquatic centres Bowling alleys Shopping centres Restaurants Art galleries

29

I have notified the other party/other party’s legal representative, and the above location/s are suitable.* This field is required.

YESNO

30

Will there be anyone else involved in the visit?* This field is required.

31

Risk Assessment* This field is required.Do you or the other party have a history of Mental health issues Alcohol/drug abuse Family Violence Harassment of others Stalking Disability Anger management issues Possession of firearms

32

Any Other Details We Should Know?

33

Parental Signature* This field is required.I agree that the information provided in this form is true and correct

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