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Child and Family Therapeutic Service (CAFTS) Referral Form

  • Child and Family Therapeutic Service (CAFTS) Referral Form
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  • Child and Family Therapeutic Service (CAFTS) Referral Form

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About CAFTS

The Child and Family Therapeutic Service (CAFTS) works therapeutically with children aged 0-18 and families impacted by child sexual abuse (CSA) or harmful sexual behaviours (HSB).

Therapeutic support can be via individual or family counselling, protective behaviours, group support or psychoeducation.

Relationship to child/ren

What is your relationship to the child who is seeking support?*

Referrer

By entering your details, you consent for Uniting WA to contact you for the purpose of assessing eligibility for this program

Please tick all areas of support that apply to this referral (can select multiple)*

What is the main issue for the child/ren / family being referred (select one)*

Family / carer details

Does child/ren being referred live with parent/s?*

Parent 1
Add another parent's details?*

Parent 2
Carer

Child/ren being referred

Child 1 being referred
Child 1 gender*

Add another child's details?*

Child 2 being referred
Child 2 gender*

Add another child's details?*

Child 3 being referred
Child 3 gender*

Add another child's details?*

Child 4 being referred
Child 4 gender*

Other agencies

Please include information for all children being referred

Does the child(ren) agree with the referral to counseling?*

Do all parents who have care of or significant contact with the child referred agree with the referral for counselling?*

Have the concerns been reported to Child Protection and/or Police?*

Nature of concerns

Please include information for all children being referred

Family / carer’s reaction to current circumstances

Purpose of the referral

Other family issues

Please include information for all children being referred

Current safety

Please include information for all children being referred

Health

Please include information for all children being referred

Emotional status

Please include information for all children being referred

Education

Please include information for all children being referred

Parent/Guardian consent

Have all parents/carers who have any parental responsibility read & agreed to referral?*
Parent/Guardian 1

Parent / Carer 1: I consent for Uniting WA to contact me for the purpose of assessing eligibility for this program*

Parent/Guardian 2

Parent / Carer 2: I consent for Uniting WA to contact me for the purpose of assessing eligibility for this program

Uniting WA

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Uniting WA acknowledges the First Nations People as the Traditional Custodians of this land on which we provide our services. We recognise their unique and spiritual connection to Country and waters. We value the oldest continuing culture in the world and pay our respect to Elders past and present.

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GET IN TOUCH

Uniting WA
10/5 Aberdeen Street
Perth WA 6000
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Phone: 1300 663 298 Email: hello@unitingwa.org.au
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Uniting WA is a community services organisation of the Uniting Church Western Australia.

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