Expression of Interest

Family Engagement and Support Educator Referral Form

Thank you for expressing your interest in Little Petal's Family Engagement and Support Educator Program. Please complete the following form, and we will follow up with you within 5 business days.
Date of Referral:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Preferred Start Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Type of Referral:

Section 1 - Referrer Details

Complete this section if you are referring on behalf of the family or self-referring.
Referrer Name:

First NameLast Name
Organisation/ Agency / Relationship to Child(ren)
Role/ Position
If professional
Phone Number
Format: 0000000000.
E-mail
example@example.com
Relationship to the Family

Section 6 – Support and Service Goals

Tick the key areas of support requested (can select more than one):
Support & Service Goals

Other

Section 7 – Funding Information

Please indicate the funding source for this service:
Funding information
If Department/Agency Funded

Section 8 – Risk and Safety Considerations

Please list any known risks, safety concerns, or special considerations for our team:
Risk & Safety Considerations:

Other

Section 9 – Consent

I confirm that the family (or I, if self-referring) consent(s) to be contacted by Little Petal regarding the Family Engagement and Support Educator program.
Parent/Guardian

First NameLast Name
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
If applicable: Professional Referral):

First NameLast Name
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Privacy Statement

The information provided in this form will be used solely for the purpose of following up on your referral. Little Petal respects your privacy and will not share your information with third parties without your consent.
Should be Empty:

Family Engagement and Support Educator Referral Form