Book A Visit

1

Full Name* This field is required.

First Name

Last Name

2

Date of Birth

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?

Court Orders

Other

6

I have read The Good Shepherd ccs's Privacy PolicyMust Read before proceeding

YES

7

I have notified the other party/other party's legal representative, and the above dates are suitable.

YES

8

Relationship to the child/children:

Mother

Father

Other

9

If "Other", type in your relationship to the child/children

10

How long do you need supervised contacts for?

11

Where does the child/children spend most of their time?

12

How many days do you see the child?

13

Type of service required:

Supervised ContactChild

Supervised Changeover

Supervised Transport

Familiarisation Session

Meet and Greet

14

Approx Commencement Date

Date

15

Current Parenting arrangement in place

Informal Parenting Plan

Interim Order

Consent Order

Final Order

16

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

17

Please tick any of the below apply

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

Psychiatric or Psychological Reports

Family Reports

18

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

19

Child/rens Names

20

Health concerns/allergies

21

Disability or mental health concerns

22

Main Language Spoken (Is an interrupter needed?)

23

Other Notes

24

Name

25

Relationship To Child

26

Address

27

Phone (M)

28

Location of contact visit (Must Include The Suburb)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.

YESNO

30

Will there be anyone else involved in the visit?

31

Risk AssessmentDo 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 SignatureI agree that the information provided in this form is true and correct

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