Family Bridge Australia Application Form

Family Bridge Australia Application Form

Important: An application form must be completed by each parent (the term “parent” includes any significant person in the child’s life requiring this service). Applications must be received from all parties before the service can progress.
About You (Parent / Applicant)
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender
Relationship to the child/children*
Email*
example@example.com
The child/children live primarily with meI am the parent/carer seeking supervised contact
Other Parent / Guardian Details
Full Name

First NameLast Name
Relationship to the child/children
Other Parent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Other Parent Email
example@example.com
YesNoUnsure
Child / Children Details
Child 1: Full Name*

First NameLast Name
Child 1: Date of Birth

MonthDayYear
Date
Child 2: Full Name

First NameLast Name
Child 2: Date of Birth

MonthDayYear
Date
Child 3: Full Name

First NameLast Name
Child 3: Date of Birth

MonthDayYear
Date
Important information about your child/children (medical, developmental, behavioural, or emotional needs)
Supervised contact visitsVirtual VisitationSupervised changeoverInterim supervision pending court outcome
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Preferred time(s)
Expected frequency (if known)
Safety Information
YesNo
If yes, please briefly outline (e.g., family violence orders, intervention orders, safety plans, substance use concerns, or other relevant matters)
Court Order & Legal
YesNo
YesNo
If yes, please briefly describe the order or agreement below and attach a copy of the most current order or agreement.
Attach a copy of the most current order or agreement

Cancelof
YesNoNot applicable
If yes, date(s) and purpose:
Communication through the service onlyCommunication allowed (please specify any limits)
If communication allowed, please specify any limits
Legal Representation (If applicable)
I am legally representedI am self-represented / do not currently have legal representation
Solicitor / Law firm
Contact person
Email
example@example.com
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Independent Children's Lawyer (If applicable)
Solicitor / Law firm
Contact person
Email
example@example.com
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Any other details you would like us to know
Emergency Contact
Name*

First NameLast Name
Relationship*
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Consent & Acknowledgement
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Family Bridge Australia Application Form

About You (Parent / Applicant)

Other Parent / Guardian Details

Child / Children Details

Safety Information

Court Order & Legal

Legal Representation (If applicable)

Independent Children's Lawyer (If applicable)

Emergency Contact

Consent & Acknowledgement