accommodation Archives

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 address*

Referrer's email*

Family / carer

*Only one set of parent / caregiver details are required

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 address*

Parent 1 email*

Add another parent's details?*

Yes

Parent 2

Parent 2's first and last name*

Parent 2 home phone*

Parent 2 address is same as Parent 1?*

Yes, same address

No, different address

Parent 2 address*

Parent 2 email*

Carer

Carer's first and last name*

Carer phone number*

Carer address*

Carer email*

Type of placement?*

Child/ren being referred

How many children are being referred?

1 child

2 children

3 children

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*

Child 1 referred for counselling?*

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*

Child 2 referred for counselling?*

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*

Child 3 referred for counselling?*

Yes

People living with child

How many people live in the house with the child?*

1 other person

2 other people

3 other people

4 other people

5 other people

Person 1

Person 1 first and last name*

Person 1 date of birth*

Person 1 gender*

Male

Female

Non-binary

Prefer not to say

Person 1 ethnicity*

Person 1 referred for counselling?*

Yes

Person 2

Person 2 first and last name*

Person 2 date of birth*

Person 2 gender*

Male

Female

Non-binary

Prefer not to say

Person 2 ethnicity*

Person 2 referred for counselling?*

Yes

Person 3

Person 3 first and last name*

Person 3 date of birth*

Person 3 gender*

Male

Female

Non-binary

Prefer not to say

Person 3 ethnicity*

Person 3 referred for counselling?*

Yes

Person 4

Person 4 first and last name*

Person 4 date of birth*

Person 4 gender*

Male

Female

Non-binary

Prefer not to say

Person 4 ethnicity*

Person 4 referred for counselling?*

Yes

Person 5

Person 5 first and last name*

Person 5 date of birth*

Person 5 gender*

Male

Female

Non-binary

Prefer not to say

Person 5 ethnicity*

Person 5 referred for counselling?*

Yes

Other agencies

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

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?*