Child and Family Therapeutic Service (CAFTS) Referral Form

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?*

I’m their family member / carer

I’m referring them

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)*

Counselling

Protective behaviours

Group support

Psychoeducation

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

Child(ren) who has/have experienced child sexual abuse (CSA)

Family where Child(ren) are at risk of CSA

Child(ren) who is/are engaging in problematic or harmful sexual behaviours

Child(ren) who have experienced problematic or harmful sexual behaviours

Date of referral*

Referrer's first and last name*

Agency/ Relationship to referred person/people*

Referrer's phone number*

Referrer's email*

Family / carer

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

Yes

Parent 1

Parent 1's first and last name*

Parent 1 home phone*

Parent 1 suburb*

Parent 1 email*

Add another parent's details?*

Yes

Parent 2

Parent 2's first and last name*

Parent 2 home phone*

Parent 2 suburb*

Parent 2 email*

Carer

Carer's first and last name*

Carer phone number*

Carer suburb*

Carer email*

Type of placement?*

Child/ren being referred

Child 1 being referred

Child 1 first and last name*

Child 1 date of birth*

Child 1 gender*

Male

Female

Non-binary

Prefer not to say

Child 1 ethnicity*

Add another child's details?*

Yes

Child 2 being referred

Child 2 first and last name*

Child 2 date of birth*

Child 2 gender*

Male

Female

Non-binary

Prefer not to say

Child 2 ethnicity*

Add another child's details?*

Yes

Child 3 being referred

Child 3 first and last name*

Child 3 date of birth*

Child 3 gender*

Male

Female

Non-binary

Prefer not to say

Child 3 ethnicity*

Add another child's details?*

Yes

Child 4 being referred

Child 4 first and last name*

Child 4 date of birth*

Child 4 gender*

Male

Female

Non-binary

Prefer not to say

Child 4 ethnicity*

Other agencies

Please include information for all children being referred

Other agencies involved with family (please provide agency name and contact details):*

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

Yes

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

Yes

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

Yes

Nature of concerns

Please include information for all children being referred

Provide details about the specific concerns you have for the family/child in relation to child sexual abuse or concerning, problematic or harmful sexual behaviours.*

Family / carer’s reaction to current circumstances

How did the disclosure occur/what was the circumstance of the concerns being raised?*

What was the reaction of the parents, carers, children and other family members to the concerns?*

Purpose of the referral

What has led you to make a referral now?*

What are your best hopes for yourself or the client/family in engaging with CAFTS?*

Other family issues

Please include information for all children being referred

Please provide details on any relevant issues such as any incidents of family and domestic violence, family separation and/or current involvement in the Family Court, any concerns around parental drug and alcohol use or mental health issues etc.*

Current safety

Please include information for all children being referred

Discuss what is currently in place to keep the child/ren safe such as VRO, Safety plan etc.*

Health

Please include information for all children being referred

Describe any physical health difficulties, physical or intellectual disabilities.*

Emotional status

Please include information for all children being referred

Describe the child/ren’s current emotional status, including challenges such as anxiety, suicidal ideation, or deliberate self-harm.*

Education

Please include information for all children being referred

Please record the school attended, whether the school is aware of the referral, and any issues that have arisen within the school environment.*

Parent/Guardian consent

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

Yes

Parent/Guardian 1

Parent / Carer 1 please sign (type) your name*

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

I agree

Parent / Carer 1: Date*

Parent/Guardian 2

Parent / Carer 2: please sign (type) your name

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

I agree

Parent / Carer 2: Date